Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community

hastings-centerAbstract: It may be the case that the most challenging moral problem of the twenty-first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker’s and Hilde Lindemann’s concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one’s identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing’s morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency.

Liaschenko J, Peter E.  Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community.  The Hastings Center Report, Volume 46, Issue S1, September/October 2016, Pages S18–S21.

 

Conscience and Conscientious Objection in Health Care

An ARC Discovery Project, running from 2015 to 2017

Summary of project

Conscientious objection is a central topic in bioethics and is becoming more ever important. This is hardly surprising if we consider the liberal trend in developments of policies about abortion and other bioethical issues worldwide. In recent decades the right to abortion has been granted by many countries, and increasingly many conservative and/or religious doctors are being asked to perform an activity that clashes with their deepest moral and/or religious values.

Debates about conscientious objection are set to become more intense given the increase in medical options which are becoming available or may well be available soon (e.g. embryonic stem cell therapies, genetic selection, human bio-enhancement, sex modification), and given the increasingly multicultural and multi-faith character of Australian society. Not only will doctors conscientiously object to abortion, and to practices commonly acknowledged as morally controversial, but some of them may also object to a wide range of new and even established practices that conflict with their personal values for example, Muslim doctors refusing to examine patients of the opposite sex.

Defining conscientious objection and identifying reliable markers for it, as well as setting the boundaries of legitimate conscientious objection through clear and justifiable principles, are difficult but pressing tasks.

This project advances bioethical debate by producing a philosophically and psychologically informed analysis of conscience, and by applying this to discussions about the legitimate limits to conscientious objection in health care.

 Personnel

Chief Investigator Dr Steve Clarke, Charles Sturt University

Chief Investigator Prof. Jeanette Kennett, Macquarie University

Partner Investigator Prof. Julian Savulescu, University of Oxford

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An Unholy Mess: Why ‘The Sanctity of Life Principle’ Should Be Jettisoned.

untitledAbstract:  The aim of this article is to present an account of an important element of medical ethics and law which is widely cited but is often confused. This element is most frequently referred to as ‘the principle of the sanctity of life’, and it is often assumed that this language has a religious provenance. However, the phrase is neither rooted in the traditions it purports to represent nor is it used consistently in contemporary discourse. Understood as the name of an established ‘principle’ the ‘sanctity of life’ is virtually an invention of the late twentieth century. The language came to prominence as the label of a position that was being rejected: it is the name of a caricature. Hence there is no locus classicus for a definition of the terms and different authors freely apply the phrase to divergent and contradictory positions. Appeal to this ‘principle’ thus serves only to perpetuate confusion. This language is best jettisoned in favour of clearer and more traditional ethical concepts.

Jones DA, An Unholy Mess: Why ‘The Sanctity of Life Principle’ Should Be Jettisoned.  The New Biothics, Vol. 22, 2016, Issue 3.

Indonesian Doctors Association refuses participation in chemical castration law

Sean Murphy*

Dr. Prijo Sidipratomo told BBC news that Indonesian doctors cannot be involved with chemical castration of convicted sex offenders “because we have to uphold medical ethics,” and must not “do anything harmful to any human being.”

His comments follow the passage of a new law in Indonesia authorizing chemical castration for paedophiles.

Interviewed by the BBC, Indonesian President Joko Widodo said,  “That’s fine if the doctors don’t want to do it.  We can use other doctors.  We could use military doctors. . . . There are lots of people who want to do it.  That’s not a problem. . .  It’s up to the doctors in Indonesia.  But if the court hands out that punishment, we will carry it out.  Military doctors or government doctors can do it.”

The BBC report does not indicate whether or not the Indonesian medical profession accepts the distinction apparently made by the President between the ethical responsibilities of physicians employed by the state and those in private practice.  It appears that the President believes that the first allegiance of physicians who are employed by the state is to the law and state policy rather than to medical ethics or conscientious convictions.  This is not dissimilar to arguments being made in Canada to the effect that physicians, as agents of the state health care system, must at least collaborate in killing patients or helping them commit suicide; some academics claim that they must actually do the killing themselves if they wish to continue in practice.

‘Freedom of conscience’ a must, says doctor

Catholic Register

Michael Swan

TORONTO – It’s rare for an hour-long, academic lecture to get a standing ovation, but Dr. Ewan Goligher earned thunderous applause from about 100 people who turned up on a cold, rainy night to hear his defence of medical conscience.

The Toronto intensive care physician and researcher has become one of the leading voices opposing efforts to force doctors to make an “effective referral” for assisted suicide.

Goligher maintains that for the sake of medicine and democratic society, doctors must have a right to conscientious objection — not just for abortion but also for assisted killing.

“Freedom of conscience in the practice of medicine has been seriously eroded in recent years,” Goligher warned at the second annual deVeber Institute lecture delivered at the University of Toronto’s Wycliffe College on Oct. 27. . . [Full text]

The Ethics of Conscientious Objection in Health Care

deVeber Institute
Annual Public Lecture with Wycliffe College at the University of Toronto

In the wake of the legalization of physician-assisted death, conscientious objection in medicine has become a matter of considerable controversy. Some bioethicists have called for severe restrictions on the physician’s capacity to object to patient requests on ethical grounds, and some Colleges of Physicians have enacted such restrictions.

This issue raises fundamentally important questions: what is the basis of the physician’s professional obligations? To what extent is the physician obligated to honour patient requests? What is the goal and purpose of medical practice? How can we resolve differences in ethical beliefs in a deeply pluralistic society? This controversy engages contested ethical, political and religious matters and promises to influence patient care and the practice of medicine in Canada in coming years. This lecture aims to chart a course through these muddied waters.

Catholic health care’s conscientious objections appropriate in Canadian health system

Edmonton Journal

Michael Shea

Re. “Catholic hospitals put religious principles ahead of patient rights,” Paula Simons, Sept. 28

As Canada implements legislation related to medical assistance in dying, members of the Catholic Health Alliance of Canada have worked together to respond to requests with integrity — ensuring that we abide by the law and continue our 400-year mission of service in keeping with our ethics and values.

Catholic health care is a vital part of the Canadian health system. Each year, more than 68,000 team members employed by 124 Catholic providers across the country serve millions of Canadians from all backgrounds and faiths with respect, honouring the beliefs and diverse cultural needs and spiritual needs of those we serve.

All Canadians have conscience and religious freedom respected under the Charter. Catholic health care has a long-standing moral tradition that neither prolongs life nor hastens death. Catholic health care’s conscientious objection to medical assistance in dying is a moral commitment to uphold the inherent value of each person while observing the law. It does not constitute a refusal to care for patients or undermine the values and rights of those in our care. . . [Full text]

Rationing conscience

journal-medical-ethicsAbstract:  Decisions about allocation of limited healthcare resources are frequently controversial. These decisions are usually based on careful analysis of medical, scientific and health economic evidence. Yet, decisions are also necessarily based on value judgements. There may be differing views among health professionals about how to allocate resources or how to evaluate existing evidence. In specific cases, professionals may have strong personal views (contrary to professional or societal norms) that treatment should or should not be provided. Could these disagreements rise to the level of a conscientious objection? If so, should conscientious objections to existing allocation decisions be accommodated? In the first part of this paper, I assess whether resource allocation could be a matter of conscience. I analyse conceptual and normative models of conscientious objection and argue that rationing could be a matter for conscience. I distinguish between negative and positive forms: conscientious non-treatment and conscientious treatment. In the second part of the paper, I identify distinctive challenges for conscientious objections to resource allocation. Such objections are almost always inappropriate.

Wilkinson D.  Rationing conscience.  J Med Ethics doi:10.1136/medethics-2016-103795

“I’m just trying to live by my conscience”

 Ottawa Citizen

Joanne Laucius

This spring, a patient told Dr. Ramona Coelho she was thinking about physician-assisted death.

Coelho gently probed to find out what was at the heart of the woman’s fear, anxiety and depression. The patient felt her life was diminished and no longer meaningful. Coelho says she steered the patient away from assisted death to finding ways to make every day seem worthwhile.

“My patients’ death wishes go away when their issues are dealt with,” says Coelho, who has practised medicine since 2007 and did palliative-care work in Montreal before moving to London, Ont., in 2012. She believes time, careful listening, affection and respect are key to a good relationship with patients. . . [Full text]