Conscience and conflict. Am J Bioeth. 2007
Dec;7(12):28-9; discussion W1-2. PubMed PMID: 18098016.
Marcus P. Adams
- Lawrence and Curlin claim that those who have recently argued for the
separation of medicine and religion "try to achieve this rhetorically"
(2007, 10). I believe that there is more than rhetoric that can be
offered in this regard. . .
- Abstract: Health care providers occasionally may find that
providing indicated, even standard. care would present for them a personal moral
problem-a conflict of conÂscience-particularly in the field of reproductive
medicine. Although respect for conÂscience is important. conscientious refusals
should be limited if they constitute an imposition of religious or moral beliefs
on patients, negatively affect a patient's health, are based on scientific
misinformation, or create or reinforce racial or socioeconomic inequalities.
Conscientious refusals that conflict with patient well-being should be
accomÂmodated only if the primary duty to the patient can be fulfilled. All
health care providers must provide accurate and unbiased information so that
patients can make informed deciÂsions. Where conscience implores physicians to
deviate from standard practices, they must provide potential patients with
accurate and prior notice of their personal moral comÂmitments. Physicians and
other health care providers have the duty to refer patients in a timely manner
to other providers if they do not feel that they can in conscience provide the
standard reproductive services that patients request. In resource-poor areas,
access to safe and legal reproductive services should be maintained. Providers
with moral or reliÂgious objections should either practice in proximity to
individuals who do not share their views or ensure that referral processes are
in place. In an emergency in which referral is not possible or might negatively
have an impact on a patient's physical or mental health, providers have an
obligation to provide medically indicated and requested care.
- While the article by Lawrence and Curlin (2007) addresses the issue of
how the conscience of caregivers is informed and what role it should play
in the complex arena of medical decision-making, there is a foundational
definition that should be addressed early in the debate. What is
conscience? . . .
Martin Luther at the bedside. Hastings Cent Rep.
2007 Mar-Apr;37(2):inside back cover. PubMed PMID: 17474344.
- The New England Journal of Medicine recently published a study that
included data on physicians' personal beliefs about three controversial
medical practices: "terminal sedation" (palliative sedation of a dying
patient), abortion after failed contraception, and prescribing birth
control to an adolescent without parental permission. Of the 1,144
respondents, 17 percent objected to "terminal sedation"; 52 percent
objected to the abortion scenario presented; and 42 percent objected to
the birth control scenario presented. . .
Dana E. Blackman
- In 1967, Mr. Jangaba Augustine Johnson entered Mr. Wheeler's
barbershop seeking a haircut. Mr. Wheeler, licensed barber and owner of
the shop, refused service to Mr. Johnson because of his race. At that
time, Mr. Johnson lived in a culture that forced him to travel from shop
to shop, or even from town to town, simply to find a barbershop or a
lunch counter that would serve him. Nearly forty years later, a woman
enters her local pharmacy holding a lawful prescription for emergency
contraception. Frightened and nervous, she hands the prescription to the
pharmacist, only to be scolded by the person looking down his nose at
her: "I will not fill this prescription. I will not help you kill your
fetus." The woman is humiliated, and, even worse, is unable to get the
drugs she badly needs to prevent an unwanted pregnancy. Living in an
isolated area, the nearest alternative pharmacy is far away and the
woman lacks transportation. Unless she is able to find a pharmacy that
will fill her prescription, she will risk facing an unintended and
unwanted pregnancy. . .
Christine Dehlendorf, Kevin Grumbach, Carole Joffe, Dalia Brahmi, Marji
Gold, David Engel, MD
- Abstract: Background and objectives: Access to abortion
services in the United States is declining. While family physicians are well
suited to provide this care, limited training in abortion occurs in family
medicine residency programs. This study was designed to describe the
structure of currently available training and the experience of residents
participating in these programs.
Methods: E-mail questionnaires were sent to key faculty members and
third-year residents in nine programs that have required abortion training.
These faculty members and a sample of residents also completed
Results: Residency programs varied in the amount of time dedicated to the
procedural aspects of abortion training, ranging from 2 to 8 days, and also
in non-procedural aspects of training such as values clarification and
didactics. Themes that emerged from interviews with residents included the
benefit of training with respect to technical skills and continuity of care.
In addition, residents valued discussion of the emotional aspects of
abortion care and issues relating to performing abortions after graduation
Conclusions: While the details of the curricula vary, residents in
programs with required abortion training generally felt positively about
their experiences and felt that abortion was an appropriate procedure for
family physicians to provide. Residents emphasized the importance of both
non-procedural and technical aspects of training.
Howard Brody, Susan S. Night
- The pharmacist's duty to dispense emergency contraception may be
approached as a legal, policy, and regulatory issue; as an ethical issue;
or as an empirical question. Card (2007) elects to analyze it as a
philosophical question having to do with professional ethics, while still
(of necessity) grounded in the scientific facts about the nature and
mechanism of emergency contraception. This approach leads Card to reject
a commonly held "moderate" position - that the pharmacist who
conscientiously objects may refuse personally to dispense the medication,
but may not refuse to refer the patient to another, willing pharmacist.
Card argues instead that the pharmacist is obligated to dispense the
emergency contraceptive. . .
Robert F. Card
- This article argues that practitioners have a professional ethical
obligation to dispense emergency contraception, even given conscientious
objection to this treatment. This recent controversy affects all medical
professionals, including physicians as well as pharmacists. This article
begins by analyzing the option of referring the patient to another
willing provider. Objecting professionals may conscientiously refuse because
they consider emergency contraception to be equivalent to abortion or
because they believe contraception itself is immoral. This article
critically evaluates these reasons and concludes that they do not
successfully support conscientious objection in this context. Contrary to
the views of other thinkers, it is not possible to easily strike a
respectful balance between the interests of objecting providers and patients
in this case. As medical professionals, providers have an ethical duty to
inform women of this option and provide emergency contraception when this
treatment is requested.
Robert F. Card
- I thank the thoughtful commentators on my essay. Their contributions
have deepened my grasp of the relevant issues. Unfortunately I cannot
discuss each selection in turn, but will instead focus on several
commentaries that purport to offer the most serious objections to my
argument. Farr Curlin (2007) argues that my paper only addresses
"straw-men" (sic) arguments and fails to accurately state the reasons
that drive opponents of dispensing emergency contraception (EC). Curlin
goes on to present several of the "real" arguments in support of medical
providers' right to refuse to dispense EC, yet curiously he does not
provide citations to the sources of these arguments. My paper does: for
instance, members of Pharmacists for Life International claim that they
will not dispense EC since this constitutes doing harm to human life and
hence violates the Hippocratic Oath (Stein 2005).Myessay certainly does
not purport to examine every conceivable reason, but it does formulate
and closely examine the reasons offered by the most vocal proponents of
providers' rights to refuse to dispense EC. . .
The Conscience of the Pharmacist.
Proceedings of the University Faculty for Life, Vol. 17 (2007) 431-437
John J. Conley
- Abstract: Recent legal efforts to force pharmacists to distribute
potentially abortifacient drugs constitute a violation of conscience.
This campaign of coercion violates religious freedom, professional
deontology, and the right to refuse even material co-operation in acts of
E. David Cook
- Jiminy Cricket's advice to Pinocchio was always to let your conscience
be your guide (Collodi, Folkland, and Murray 2000). But in calling for
physicians "to specify their definitions of the conscience and the
reasons for and implications of those definitions" (Lawrence and Curlin
2007, 10), there is a need to define exactly what we mean by the term
conscience. Traditionally, conscience covers two main aspects. The first
is conscientia, which refers to the inner knowledge of what is right and
wrong. The second synderesis - applying your moral principles to actual
situations (Fagothey 2000; Gladwin 1977; Wood 2006). Interestingly,
the root of the word conscience implies knowledge and agreement with
- 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 statesâ€™ explanations of when abortion is lawful, and
governments are increasingly inspired to publicize regulations or
guidelines on when abortion will attract neither police nor prosecutorsâ€™
Farr A. Curlin
- Card (2007) joins many others (Charo 2005; Savulescu 2006) who are
disturbed that clinicians would refuse on moral grounds to provide or
help patients obtain emergency contraception (EC) or other legal but
controversial clinical practices. Card's essay purports to meet these
clinicians in the ring of moral discourse and knock them out fair and
square. Yet, further scrutiny suggests the vanquished are only strawmen
substitutes for the real opponents, and instead of boxing by the rules,
Card has taken off the gloves and thrown 'the kitchen sink' instead. If
this approach wins, ethics loses. . .
Curlin FA, Lawrence RE, Chin MH, Lantos JD.
Religion, conscience, and
controversial clinical practices. N Engl J Med. 2007 Feb
8;356(6):593-600. PubMed PMID: 17287479; PubMed Central PMCID: PMC2867473.
Farr A. Curlin, Ryan E. Lawrence, Marshall H. Chin, John D. Lantos
- Background: There is a heated debate about whether health professionals
may refuse to provide treatments to which they object on moral grounds.
It is important to understand how physicians think about their ethical
rights and obligations when such conflicts emerge in clinical practice.
Methods : We conducted a cross-sectional survey of a stratified, random
sample of 2000 practicing U.S. physicians from all specialties by mail.
The primary criterion variables were physicians' judgments about their
ethical rights and obligations when patients request a legal medical
procedure to which the physician objects for religious or moral reasons.
These procedures included administering terminal sedation in dying
patients, providing abortion for failed contraception, and prescribing birth
control to adolescents without parental approval.
Results: A total of 1144 of 1820 physicians (63%) responded to our
survey. On the basis of our results, we estimate that most physicians
believe that it is ethically permissible for doctors to explain their
moral objections to patients (63%). Most also believe that physicians are
obligated to present all options (86%) and to refer the patient to another
clinician who does not object to the requested procedure (71%). Physicians
who were male, those who were religious, and those who had personal
objections to morally controversial clinical practices were less likely
to report that doctors must disclose information about or refer patients
for medical procedures to which the physician objected on moral grounds
(multivariate odds ratios, 0.3 to 0.5).
Conclusions: Many physicians do not consider themselves obligated to
disclose information about or refer patients for legal but morally
controversial medical procedures. Patients who want information about and
access to such procedures may need to inquire proactively to determine
whether their physicians would accommodate such requests.
Inmaculada de Melo-Martin
- As Robert Card (2007) shows, the refusal of some pharmacists to fill
prescriptions for emergency contraception on conscientious grounds has
resulted in significant public debate. Indeed, several state legislatures
now protect the right of pharmacists to refuse to fill legally valid
prescriptions because of personal beliefs (Guttmacher Institute 2007).
Although much of the discussion has focused on trying to find a
moderate position that would balance the right of pharmacists to not
participate in activities that they find objectionable with the needs of
patients, little attention has been given to whether such middle ground
is as unproblematic as it seems. Card's work attempts to fill this gap by
showing that such a moderate position is in fact questionable.
The BMA has clashed with the UK General Medical Council about draft
guidance from the GMC for doctors who object to providing certain
medical services on the ground that they conflict with their personal
beliefs. In its response to the draft of Personal Beliefs and Medical
Practice the BMA argues that the guidance goes beyond doctors' widely
accepted right to opt out of certain procedures that involve matters of
life and death, such as abortion, contraceptive services, and the
withdrawal of life prolonging treatment. The association claims it could
confuse patients and give doctors a licence to discriminate. . .
Emerson CI, Daar AS.
Defining conscience and acting conscientiously.
Am J Bioeth. 2007 Dec;7(12):19-21; discussion W1-2. PubMed PMID: 18098011.
Claudia I. Emerson, Abdallah S. Daar
- Lawrence and Curlin (2007) claim that disputes around what
significance and role the conscience should take in the practice of
medicine can be better understood by recognizing the definition of
conscience that is presupposed by disputants. They succeed in their
objective to "draw attention to and promote discussion about the
plurality of ways that the conscience is described, and the differing
roles the conscience is said to have" (2007, 10), but it is unclear how
much this can actually contribute to mitigating the underlying conflict,
which ultimately centers on whether a physician is ever justified in
invoking conscientious objection at the expense of those she is meant to
Emily W. Evans
- In Texas, three pharmacists are fired for refusing to fill a rape
victim's prescription for emergency contraception because it "violated
[their] morals." A Wisconsin pharmacist refuses to fill, or transfer
out, a similar prescription and is put on trial for violating the state's
regulation and licensing department's standards of care. He stated
that he "did not want to commit a sin." A group of Illinois pharmacists sue
their employer for religious discrimination after they were each
disciplined for refusing to fill prescriptions for emergency
contraception. . .
Nancy J. Girard
- Somewhere in their curricula, schools of nursing and institutions
that teach perioperative nursing usually address the concept of "surgical
conscience." Course competency statements and learning outcomes often
include criteria mandating that the student will demonstrate surgical
conscience as evidenced by consistently exhibiting ethical behavior,
promoting patient safety, and doing the right thing even when no
external monitors are present (although it is unclear how it could be
determined that surgical conscience was being exercised without someone
watching). The importance of listening to one's surgical conscience
may or may not be drilled into students, depending on the institution
and the instructor.
A. L. Glasberg, S. Eriksson, A. Norberg
- Abstract: Aim. This paper reports a study
examining factors that may contribute to burnout among healthcare
Background. The impact on burnout of factors such as workload and
interpersonal conflicts is well-documented. However, although health care
is a moral endeavour, little is known about the impact of moral strain.
Interviews reveal that healthcare personnel experience a troubled
conscience when they feel that they cannot provide the good care that
they wish â€“ and believe it is their duty â€“ to give.
Methods. In this cross-sectional study, conducted in 2003, a sample of
423 healthcare personnel in Sweden completed a battery of questionnaires
comprising the Maslach Burnout Inventory, Perception of Conscience
Questionnaire, Stress of Conscience Questionnaire, Social Interactions
Scale, Resilience Scale and a personal/work demographic form.
Results. Regression analysis resulted in a model that explained
approximately 59% of the total variation in emotional exhaustion. Factors
associated with emotional exhaustion were 'having to deaden one's
conscience', and 'stress of conscience' from lacking the time to provide
the care needed, work being so demanding that it influences one's home
life, and not being able to live up to others' expectations. Several
additional variables were associated with emotional exhaustion. Factors
contributing to depersonalization were 'having to deaden one's
conscience', 'stress of conscience' from not being able to live up to
others' expectations and from having to lower one's aspirations to
provide good care, deficient social support from co-workers, and being a
physician; however, the percentage of variation explained was smaller
Conclusion. Being attentive to our own and others' feelings of troubled
conscience is important in preventing burnout in health care, and staff
need opportunities to reflect on their troubled conscience.
Further research is needed into how a troubled conscience can be eased,
particularly focusing on the working environment.
Linda MacDonald Glenn, Jeanann Boyce
- Lawrence and Curlin (2007) outline the two traditional paths that help
define 'conscience': the fundamentalist approach and the secular
approach. These paths fall into the classic dualistic notion that the
world is made up of divisions between the self and the other, mind and
body, consciousness and form, good and bad, here and there, past and
future (Wilber 2001, 69). The difficulty with this notion is that it
suggests that decisions are being made in a moral vacuum: it sets up
an "us versus them" adversarial scenario, rather than establishing a
basis for trust, the foundation of the physician - patient relationship.
Haddad A. A matter of conscience. RN. 2007 Apr;70(4):24. PubMed
- May I refuse to care for patients with AIDS by raising a conscientious
objection? As long as a patient isn't abandoned, you can refuse to
perform an action based on conscience. But in the case of a patient who is HIV-positive or has AIDS, it's hard to
imagine how your objection could be based on this reasoning. . .
John J. Hardt
- I am a proponent of the validity of conscience as a moral determinant
of action in the clinical encounter. But there is much with which I agree
in Professor Card's article (2007). The use of pharmacists and physicians
as gatekeepers is a problem that needs to be resolved if conscience is
going to be protected and patient access to legal medications is going
to be assured. The moral necessity of allowing one to follow the dictates
of conscience and the social good of making legally-sanctioned
medications readily available must jointly be preserved.
Conscience and the ends of
medicine. Paper delivered to the President's Council on Bioethics,
November 8, 2007.
John J. Hardt
- . . .This morning, I hope to build upon Dr. Pellegrino's closing
comments from your meeting of September 6 in which he recognized
something of an identity crisis in medicine today. He suggested that we
ought to attend to the current confusion concerning the profession's
understanding of its own relationship to society, a confusion that Dr.
Pellegrino suggested might be resolved, at least in part, by what he
called a "reprofessionalization," a kind of reestablishment of the moral
foundations of medicine that would undergird the traits that
characterize "professionalism" - as he described them: competence,
fidelity, and trust - with a normative moral vision of the profession
I think that the recent debates concerning conscience
in the clinical encounter are an important expression of this confusion
about medicine's relationship to society noted by Dr. Pellegrino. I say this
because I wonder if the question of conscience's role is, at its core, a
question about how medicine, individually embodied in the physician, relates
to society, individually embodied in the patient. . .
- Introduction: During the past few years, the debate over whether
health care professionals should be required to provide services that
conflict with their personal beliefs has focused primarily on pharmacists
refusing to fill prescriptions.1 According to one media account, during a
sixmonth period in 2004 there were approximately 180 reports of
pharmacists refusing to dispense routine or emergency oral
contraceptives. 2 This controversy, however, extends beyond the pharmacy
into every facet of the heath care system. . .
Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin
- 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
Asim Kurjak, Jose Maria Carrera, Laurence B. McCullough,
Frank A. Chervenak
- Abstract: In this paper we show that the question, "When does human
life begin?", is not one question, but three. The first question is,
"When does human biological life begin?", and is a scientific question. A
brief review of embryology is provided to answer this question. The
second question is, "When do obligations to protect human life
begin?", and is a question of general theological and philosophical
ethics. A brief review of major world religions and philosophy is
provided to answer this question but has no settled answer and therefore
involves irresolvable controversy. The third question is, "How should
physicians respond to disagreement about when obligations to protect
human life begin?" and is a question for professional medical ethics. A
review of the ethical concept of the fetus as a patient is provided to
answer this question. Physicians should manage the irresolvable
controversy surrounding the second question by appealing to the ethical
concept of the fetus as a patient. It is phi losophically sound,
respectful of all religious traditions and the personal convictions of
patients and physicians alike, and clinically applicable.
Some reflections on conscience. Am J Bioeth. 2007
Dec;7(12):32-3; discussion W1-2. PubMed PMID: 18098018.
Rosalind Ekman Ladd
- When we say to physicians, "Don't impose your values on your
patients," we are articulating a basic principle integral to a
pluralistic society. And for those who subscribe to this principle, it
does not really matter how the values were formed. Thus, while it is
interesting and doubtless true that the values underlying individual
conscience may have their source for some people in religion and for
others in a secular, rationalistic tradition, it is not at all clear
that, as Lawrence and Curlin (2007) claim, recognizing the clash of
definitions that arises from the different sources of conscience will
either advance a more robust conversation about the reasons and ends
of medicine or help resolve any of the controversial problems in
bioethics. . .
The physician's conscience. Am J Bioeth. 2007
Dec;7(12):15-7; discussion W1-2. PubMed PMID: 18098009.
- Lawrence and Curlin claim that we fail to resolve issues about medical
professionals' claims to rights of conscience because we do not attend
appropriately "to the possibility that disputants are operating with
contrasting definitions" (2007, 10). If we appreciated these differences,
then "new light will be cast on current controversies and new strategies
will emerge for negotiating accommodations between those who disagree"
(2007, 10) I am not so sure. I suspect that most people who are
familiar with these issues understand all too well that disputants
operate with different views (not different definitions) of conscience.
Eva LaFollette, Hugh LaFollette
- In the US, ambulance drivers have refused to transport patients for
abortions, a fertility clinic refused to assist a gay woman and a
pharmacist refused to give the morning-after pill to a rape victim.
In the UK, the Catholic Church claims to be exempt from laws forbidding
adoption agencies from discriminating against homosexuals. A growing number
of pro fessionals now assert a right of conscience, a right to refuse to
do anything they deem immoral, and to do so with impunity. Such claims
emerged 40 years ago when some doctors and nurses claimed a right to
refuse to perform (or assist in performing) an abortion. . .
Ryan E. Lawrence, Farr A. Curlin
- What role should the physician's conscience play in the practice of
medicine? Much controversy has surrounded the question, yet little attention
has been paid to the possibility that disputants are operating with
contrasting definitions of the conscience. To illustrate this divergence, we
contrast definitions stemming from Abrahamic religions and those stemming
from secular moral tradition. Clear differences emerge regarding what the
term conscience conveys, how the conscience should be informed, and what
the consequences are for violating one's conscience. Importantly, these
basic disagreements underlie current controversies regarding the role of the
clinician's conscience in the practice of medicine. Consequently
participants in ongoing debates would do well to specify their definitions
of the conscience and the reasons for and implications of those
definitions. This specification would allow participants to advance a more
philosophically and theologically robust conversation about the means and
ends of medicine. . .
Ronald A. Lindsay
Robert Card (2007) provides a thoughtful and timely analysis of an
important public policy issue. Unfortunately, the significance and force
of his analysis is considerably limited by his decision to forego
discussion of the legal and regulatory framework for conscientious
objector status and focus almost exclusively "on professional ethical
obligations" (2007, 8). The primary concern of persons seeking emergency
contraception (EC) is not whether physicians or pharmacists might
disapprove of a fellow professional who refuses to prescribe or dispense
EC. These persons want EC and they want some pressure applied to those
who would deny them EC that is more forceful and effective than moral
- Aim: To investigate gynecologists' and midwives' views and experiences
regarding work in abortion care in Sweden.
Methods: Questionnaire to
gynecologists (n=269) and midwives (n=258) comprising 48 questions,
response 85%. The quantitative studies (articles I-III) were supplemented by
a qualitative study (article IV), consisting of focus-group interviews
with gynecologists and midwives/nurses.
Results: From the
questionnaire studies it was apparent that all the gynecologists had worked
in abortion care, whilst not all midwives had done so. The male
gynecologists were older than both their female colleagues and the
midwives; they had most years of experience but were now working least
with abortion patients. Both groups considered it absolutely right, that
Sweden have legal abortion and that the law was being followed. Most thought
that women should be allowed to have an abortion even after they had felt
fetal movements. The midwives were generally somewhat more restrictive
than the gynecologists. Half of all thought that the work with abortion
patients brought something positive with it. Those having worked longest
and most extensively, especially during the previous year were most liberal.
Both groups felt that there was a difference between working with
surgical and late abortions compared with medical abortions. One in four
had had misgivings when involved in surgical and medical abortions, and
one in two with abortions after the 18th week. All were positive about the
transition to medical abortions, and roughly two thirds of the midwives
thought that the primary care sector should be able to take care of
these, whereas less than half of the gynecologists thought this. The
majority considered it important to receive further and continuing
professional development and ongoing guidance. From the focus-group
interviews it was clear that the experiences of the gynecologists were
largely connected with the technical development of abortion methods and
those of the midwives/nurses with improved pain relief. The work was
sometimes described in paradoxical terms and was occasionally experienced
as frustrating, especially in connection with repeat abortions. Neither of
the two groups, however, had had any doubts about participating in
abortion. The gynecologists described how women now expected to get an
abortion, whereas previously they had asked for one. The midwife/nurse
group maintained that the meetings with the women had become considerably
more frequent. The interaction between the two professional groups was
marked by great trust in each other's professional competence.
Conclusions: Gynecologists and midwives working in abortion care support
Swedish abortion legislation and have no doubts about participating in
abortions, despite the fact that they have frequently experienced complex
and difficult work situations. The character of the work is experienced
as contradictory and frustrating, but also as challenging and rewarding. The
awareness that the two professional groups have of the importance of
continuing professional development and ongoing guidance should be acted
on. Furthermore, their collective views and experiences should be made
use of, so that abortion care can be developed, not only in order to
promote women's health, but also to improve the work environment for the
Greg Loeben, Michelle A. Chui
- Speaking generally, we find a great deal of the argumentation in
Card's (2007) article to be incomplete. For example, although Card claims
to have argued that referral is not an ethically acceptable alternative
to dispensing emergency contraception (EC), it seems far more accurate to
say, in addition to Carson Strong (2007), that the author has in fact
only shown that the option of referral may not be ethically acceptable to
some conscientious objectors. . .
- From the outset, the concerns of this book are clearly Catholic concerns.
It deals with the problems of conscience Catholics may have when carrying
out their duties in everyday life. Whether it can bridge the gap in order
to appeal to a wider audience is questionable, but there is certainly a
lot to consider in this collection. Consisting of 15 thought-provoking
essays, it is nothing if not comprehensive. These essays were first
presented at the 2003 International Conference of the Linacre Centre for
Healthcare Ethics on Cooperation in Evil and Conscientious Objection. The
arguments put forward in this book offer interesting and often
sophisticated insights into the many facets these problems can take. At
times, however, it may appear to the non-Catholic that these problems are
more apparent/created than real. . .
Christopher Meyers, Robert D. Woods
- Robert Card has written an important and careful paper (2007). It is
important because this is clearly a pressing issue with powerful politics
attached. One need only do a web search for "pharmacists and conscience"
to see the kind of heated rhetoric driving the conversation, which is why
Card's careful and discerning examination is of such value.
Heconvincingly analyzes the issues at stake, includingsome of the key but
subtle points. While we might quibble with a few of his specific lines
of reasoning (for example, we think there is an important difference
between conscientious objection and civil disobedience), we want instead
to discuss Card's key suggestion toward the end of the essay.
Susan S. Night
- Conscientious objection by healthcare professionals, in particular
physicians, is not necessarily a recent phenomenon but of late there have
been efforts to vastly expand this concept in the clinical setting. It is
fairly well settled in law and policy that physicians have a moral duty to
their own personal integrity to refuse to participate in abortion
procedures if doing so would compromise a strongly held religious or
philosophical belief. However, other areas where physicians may also
express an objection, such as a refusal to prescribe needed medication
because it is derived from stem cells or provide fertility services to
gay persons, remain controversial. . .
- Abstract: U.S. health care is at a
crossroads. It faces many challenges--the most evident being
unsustainable cost increases and diminishing access. For decades,
attempts at reform have been unsuccessful. One reason our traditional
approaches have not worked is that we who serve the ministry have not
brought to those efforts sufficient reflection concerning the deeper,
values-level attitudes concerning reform. Instead, the reform movement
has concentrated on promoting particular policy solutions. Ultimately,
of course, we must agree on a delivery and financing system if we are to
redress the situation. But first we must recognize that U.S. health
care's fundamental challenge is moral and social in nature. Stakeholders
will not let go of the status quo until a critical mass of people
becomes convinced that there is a serious moral and social imperative to
do so. Social change of this magnitude is not simply a matter of
comprehensive new policy. To be effective, it must be accompanied by
sustained individual and public conscience work that grounds a
significant social movement comprising a critical mass of each of those
stakeholders. Several principles from the Catholic tradition--the common
good, solidarity, and stewardship--are particularly relevant to the
individual and public conscience work necessary in the health care
reform movement. Health care professionals and organizations are
simultaneously part of the solution and part of the problem. By keeping
this interior dialogue alive, in ourselves and in our work communities,
we are much more likely to get at the root causes of our unjust health
system and to contribute to the larger social movement that brings about
more health care justice. This article contains a "conscience work
exercise" that will help individuals and organizations examine and
identify the values, attitudes, and dispositions that contribute to
health care justice and those that keep us mired in the status quo.
- Nursing and other health care disciplines have a longstanding tradition
of conscientious objection. Clinicians can refuse to participate when
they believe that it would be morally wrong to give the treatment
requested by a patient. In the USA, the right to refuse participation in
certain forms of treatment based on religious or conscientious objections
is enshrined in the laws of many states and in the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) standards.1 Until recently
this standard was uncontroversial and was considered an essential way for
clinicians to preserve their own moral autonomy. Two recent conscientious
objection cases show the need for reconsideration of this standard: the
first was the refusal by some pharmacists to dispense birth control
agents, and the second the refusal of Catholic hospitals receiving public
funds to dispense morning-after birth control prescriptions to rape
Robert D. Orr
- Lawrence and Curlin (2007) have addressed the question of what role a
physician's conscience should play in his or her practice of medicine by
drawing some insightful distinctions in definitions of conscience. They
have focused on different understandings of conscience in religious and
secular traditions. In addressing the question of the consequences of
not following one's conscience, the authors distinguish between divine
retribution for the religious physician and temporal consequences for
physicians applying secular reasoning (Lawrence and Curlin 2007). They do
not, however, go beyond this question to address the issue of moral
complicity. . .
- In this article, the author - a Bishop of the Catholic Church-
discusses the similarities and differences between two sets of ethical
values that may guide the behaviour of medical professionals towards
their patients and society. One set derives from Biblical principles
contained in the Old and New Testaments, mainly represented by the Ten
Commandments and Christ's Prayer from the Mountain. These principles are
shared by all Christian nominations and by the Jewish and Muslim
religions. The second one, although intrinsically agnostic, is also
focused in the human individual and the human society. Both streams obey
a "natural morality" common to all humans: every individual should respect
each one's conscience, should avoid doing to others what each one would
not like to receive, to do not lie, kill or rob, to obey the rules of
family and society. The Biblical Ethics stresses the value of
responsibility in human behaviour while Modern Ethics sets the point in
authenticity. In spite of their differences, the sharing of crucial
points and end goals should inspire medical professionals regardless
their religious beliefs to follow a common set of ethical values and to
remain united in pursuing it.
Healthcare without conscience--unconscionable! Ann
Pharmacother. 2007 Nov;41(11):1903-5. Epub 2007 Oct 16. PubMed PMID:
- The American public and government response to media reports of
pharmacists refusing to fill prescriptions due to moral objections could
fundamentally alter health care. Denying one group of citizens the right
to act on their conscience puts each citizen in jeopardy of losing First
Amendment rights. Denying healthcare professionals the right to act on
their conscience puts patients at risk of being cared for by those who
are less than professional, those whose character attributes essential to
quality care are compromised. We can define better solutions for access
to legal prescriptions and therapies without demanding that healthcare
professionals become complicit in activities they deem immoral.
- There has been much recent debate about what role conscience should
play in the delivery of medicine. Lawrence and Curlin argue that
disputants in this debate "are operating with contrasting definitions of
the conscience" (2007, 10). They go on to argue that "differences emerge
regarding what the conscience conveys, how the conscience should be
informed, and what the consequences are for violating one's conscience"
(10) and that this can account for some of the dispute. I disagree that
it is differences in conceptions of conscience that can account for this
dispute. I will locate the cause of this dispute not in different
concepts of conscience but in different understandings of the role of
values in the delivery of medicine. . .
Introduction: On May 4, 2005, convicted Texas child molester Larry
Don McQuay was released from prison. Again. McQuay, who had been a
school bus driver in San Antonio, Texas, had been initially sentenced to
eight years in prison for molesting a six-year-old boy in 1989. McQuay
begged the state of Texas to surgically castrate him so that he would not
repeat his crimes, which he admitted included molesting over 200
children. McQuay stated that when he looks at a child, " 'I see a sex
object . . . . I hate the things that I do. I'm just scaredthat it's going
to happen. That's why I want to get the surgery.' " His request was
denied. McQuay's letters from prison prompted the citizens'
organization, Justice for All, to help him raise the funds to obtain the
surgery privately. Although the organization was successful in raising the
funds, they could find no physician who was willing to perform the surgery.
Imperative for Ectogenesis. Cambridge Quarterly of Healthcare Ethics
(2007), 16, 336â€“345.
- The United Kingdom, like many other affluent Western societies, is
apparently in the grip of declining fertility. The resultant strain on
the economy caused by an aging population is being exacerbated by what
has been characterized as the selfishness of women who delay
reproduction in their efforts to secure financial and social status
before getting around to starting a family. Such women may only begin
to think about having children in their mid-30s, an age that, according
to research, is a predictor of "serious morbidity" in pregnancy and
childbirth. And for many of those who try to start families when in their
30s, their fertility may have declined so that they may not be able to
have children at all or may need to resort to reproductive therapies to
do so. . .
Stotland NL, Ross LF, Clayton EW, Mishtal JZ,
Chavkin W, Zarate V, O'Connell P, Mistrot J, Parsons KC, Curlin FA,
Lawrence RE, Chin MH, Lantos JD.
Religion, conscience, and controversial clinical
practices. (Letters and authors' reply) N Engl J Med. 2007 May 3;356(18):1889-92. PubMed PMID: 17476021.
Nada Stotland, Lainie F. Ross, Ellen W. Clayton,
Joanna Z. Mishtal, Wendy Chavkin, Victor Zarate, Patrick O'Connell, Jacques
Mistrot, Kenneth C. Parsons, Farr A. Curlin, Ryan E. Lawrence, Marshall H.
Chin, John D. Lantos
- Stotland: The policy of the American Medical Association states,
"The patient has the right to receive information from physicians and to
discuss the benefits, risks, and costs of appropriate treatment
alternatives." . . .
Ross, Clayton: More disturbing than the data
described by Curlin et al. is the authors' conclusion: "Patients who want
information about and access to such procedures may need to inquire
proactively to determine whether their physicians would accommodate such
requests." . . .
Mishtal, Chavkin: Curlin et al. provide
documentation that patients may not receive information about medical
options because of the religious beliefs of their physicians. The history of
Poland shows how a conscience clause can lead to the systemic deprivation of
services. . .
Zarate: The findings of Curlin et al. are
timely for Chile, where there is a fierce controversy about whether the
morning-after pill should be prescribed for girls as young as 14 years of
age without their parents' consent. . .
O'Connell, Mistrot: Curlin et al. note the
association between physicians' religiosity and their decreased willingness
to refer patients for interventions that the physicians find morally
objectionable, and the authors place this association within the context of
paternalism versus patient autonomy. . .
Parsons: Until recently, I was an attending
physician for patients with spinal cord injury during their initial
rehabilitation. Many of those patients were on life support and despaired of
going on with life, voicing a request for termination of their lives.
Decisions based on patient autonomy alone would have had us doing so. . .
Curlin, Lawrence, Chin, Lantos (authors): If a
judgment of conscience were merely a statement of personal preference or an
expression of prejudice, the claims of Dr. Stotland and Drs. Ross and
Clayton would be justified. But anyone who has been hounded by a sense
that he or she has acted wrongly knows that is not how the conscience works.
- Robert F. Card (2007) argues that pharmacists who conscientiously
object to filling prescriptions for emergency contraception (EC) should,
despite their personal views, always fill them. His view, according to
which a pharmacist's conscientious objection concerning EC should always
yield to the patient's interests, is at one extreme of a spectrumof
possible views. The opposite extreme, that a pharmacist's right to
conscientious objection concerning EC is never overridden by patient
interests, has been advocated by others (Stein 2005). A middle-ground
view might be something like this: when conscientious objection can occur
without an undue risk of harm to the patient, it is permissible; when it
cannot be performed without such risk, the pharmacist's duty to
promote the interests of the patient overrides the right to conscientious
objection. This wording of the middle ground view leaves open the
definition of an undue risk and suggests that a variety of views is
possible. I believe that both of the extreme views are mistaken, but here
I shall argue only that the defense Card puts forward for his view is
defeated by several serious objections. . .
- Conclusion: When a woman and her physician decide
that a prescription for con-traception is in her best health interests,
legal, professional, and ethical obligations should prevent a pharmacist
from being able to effectively override that determination. The right of
a pharmacist to abide by her moral or religious principles when faced
with a prescription that goes against those principles is an important
right to protect. However, this right should never be allowed to
infringe on a patientâ€™s right to access birth control, an equally
important right that has significant implications for the majority of
American womenâ€™s reproductive health. Pharmacist refusal clauses
acknowledge pharmacistsâ€™ right to refuse at the expense of womenâ€™s right
to access contraceptives, inappropriately reconciling these rights.
Griswold v. Connecticut may be forty years old, but the is-sues
debated before the Supreme Court then have risen anew today, this time
behind the pharmacy counter. Following in the footsteps of the
Griswold Court, we must now reaffirm that women have the right to
make their own family planning decisions, including the decision to use
contraception. Legislatures, pharmacy boards, pharmacies, pharmacists,
and patients must work together to put the needs of patients back where
they belongâ€”as the first priority of the pharmacy profession.
Mark R. Wicclair
- Lawrence and Curlin (2007) argue that a major source of disagreement
about the proper role of conscientious objection in medicine is traceable
to differing definitions of "the conscience." To support this claim, they
present two conceptions of conscience: a religious conception associated
with "Abrahamic religions" (i.e., Christianity, Judaism and Islam) and
a secular conception. . .
Mark R. Wicclair
- Robert Card (2007) argues against even a limited consciencebased 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? . .
- Robert Card (2007) concludes that healthcare workers - and in
particular, pharmacists - should not be granted a right to conscientious
objection with regard to providing "Plan B" or emergency contraception
(EC). He argues for this conclusion by seeking to show that their
objection, however it is construed, lacks substance. Because their
objections to providing EC are patently wrong, they can claim no special
dispensation and must fulfill their professional obligations.At first
glance, this seems shockingly retrogressive. At the commencement of the
modern era, protracted wars were fought in which each side tried to
enforce its version of truth. The upshot of those bloody efforts - in
combination with an emerging ideal of personal liberty - yielded a
principle of toleration. . .