- Abstract: All medical specialists struggle with
problems that cannot be solved with medical knowledge alone. The field
of gynecology is not unique in medicine for the presence of ethical
dilemmas, but the nature of the dilemmas are unique. Gynecologists
commonly confront complex ethical questions in their practices that can
be answered only through thoughtful consideration of the values,
interests, rights, goals, and obligations of those involved. In this
paper, three ethical issues that commonly arise in the practice of
gynecology are presented: adolescent confidentiality regarding
reproductive health services, physician conscience and provision of
abortion services, and the question of accommodating patient choice of
provider gender. Each topic is introduced with a case vignette followed
by an analysis of the issues involved and recommendations for
resolution.
- Abstract: A major reason that The Netherlands
has taken a different approach to the rest of the world on such a
fundamental moral issue is that the courts and legislature in that
country have accorded the interests of doctors a cardinal role in the
euthanasia debate. This article argues that the interests of doctors are
of only incidental and peripheral relevance in relation to the moral
status of euthanasia. The moral status of euthanasia has little to do
with the preparedness of doctors to administer the lethal injection or
their general attitude towards the practice. Euthanasia is principally
about the interests of the patient and the impact that the practice may
have on the community in general, not preserving the conscience or
improving the working life of doctors.
J. David Bleich
- Rabbinic lore relates an anecdote, probably apocryphal, portraying
a lively student who flits from person to person in the study hall.
To each one he says, I have an answer. Ask me a question! I do not
claim to have a resolution to the dilemma posed when a conflict
arises between a patient's rights and a physician's conscience,
certainly not a facile one. My real task is to convince those in a
position to implement a solution that a problem exists and that it
merits serious consideration. Patient autonomy certainly deserves
both moral respect and legal protection, but to demand of a physician
that she act in a manner she deems to be morally unpalatable not only
compromises the physician's ethical integrity, but is also likely to
have a corrosive effect upon the dedication and zeal with which she
ministers to patients. . .
Jennell Charles
- A press release dated July 12, 2001, was titled Ohio Nurses
Association: Going to the Hospital? Nurses Warn: Don't Count on
Safe Care. In that press release, Joyce Shaffer, RN, writes that
"patients are at risk in our hospitals because there aren't enough
registered nurses on staff or on duty, hospital cost-cutting has
put nurses at risk, too, assigning responsibility for more patients
than we can safely care for and forcing mandatory overtime that's
stressful, increases errors, and jeopardizes our own health." . . .
Frank A. Chervenak, Laurence McCullough
- Case Scenario: At one of our group-practice meetings, we agreed
that we could not require partners to perform services to which they
had moral objections. For example, some of us had wanted to offer our
patients medical abortion, but we had agreed that none of us would offer
this service so we could accommodate the views of our other partners.
The discussion led to some soul searching, during which time some of
our physicians said that they were morally opposed to prescribing birth
control. We therefore agreed that, in keeping with our effort to present
a unified policy, we also could not offer prescription birth control.
However, this conclusion created an uncomfortable situation because it
meant that to accommodate the religious views of some of our
physicians, we would have to deny important medical services to
thousands of patients who did not have many health care options. In
addition, the moral issues became economic issues because so many of our
patients come to us seeking contraceptive management. Many patients
became angry and left our practice when they were told that their
physician would no longer prescribe birth control. The issue
threatened to break up our group. . .
- Abstract: In front of the evolution of medicine and
biotechnology, health care workers are called upon to take part within
new biomedical practices, that may overcome the limit of acceptability,
as it is perceived by their moral conscience. Issues as abortion,
euthanasia, assisted suicide, artificial fertilisation, experimentation
on human embryos and prescription of contraceptives and abortifacients
call into play the right to conscientious objection of health care
personnel, and in some cases, perhaps of physicians and pharmacists too.
This recall--already present in many codes of professional conduct and
medical ethics--sounds today as a necessity, which asks for a serious
deepening of the content, the applicability and the new hypothesis of
conscientious objection, in the light of bioethics and law. In
particular, the self-determination and often exasperated autonomy of the
patient within these practices makes a new principle of professional
integrity arise, to protect the physician's conscientious convictions,
if the request of the patient or society seem to violate some
fundamental human values.
Harvey MT, What does a 'right' to
physician-assisted suicide (PAS) legally entail? Theoretical Medicine
23: 271–286, 2002.
M.T. Harvey
- Abstract. "What Does a Right to Physician-Assisted
Suicide (PAS) Legally entail?" Much of the bioethics literature
focuses on the morality of PAS but ignores the legal implications of
the conclusions thereby wrought. Specifically, what does a legal right
to PAS entail both on the part of the physician and the patient? I
argue that we must begin by distinguishing a right to PAS qua "external" to a particular physician-patient relationship from a
right to PAS qua "internal" to a particular physician-patient
relationship. The former constitutes a negative claim right in rem
that prohibits outside interference with the exercise of a right to
PAS while the latter can provide the patient with a positive claim
right in personam to obligatory assistance from his physician.
Importantly, I argue that the creation of such a patient right,
however, originates with the physician who may exercise an
unqualified right of first refusal prior to promising to help her
patient commit suicide. In doing so, I hope to establish that
explicit physician promises of assistance in dying should become
legally binding. As such, current PAS law in both the Netherlands and
Oregon is in need of substantive modification.
Cynthia K. Hosay
- Abstract: Nursing home patients have a
constitutional right to refuse treatment. The Patient
Self-Determination Act confirmed that right. State laws address the
obligations of health care providers and facilities to honor that right.
The New York State law is more specific than those of many other
states. It allows exemptions for "reasons of conscience" and imposes
a number of requirements on nursing homes claiming such an exemption,
including the transfer of a patient to a home that will honor an
end-of-life wish. This study, conducted by FRIA,1 investigated the
refusal of some nursing homes in New York City to carry out patients'
end-of-life wishes because of consciencebased objections. The study
also investigated the willingness of homes which did not have such
policies to accept patients transferring from a home with a policy so
that the patient's end-of-life wishes would be honored. Implications
for administrators, policy makers, and regulators are discussed.
C. Kahlenborn, J.B. Stanford, W.L. Larimore
- Objective: To assess the possibility of a postfertilization effect in
regard to the most common types of hormonal emergency contraception (EC)
used in the US and to explore the ethical impact of this possibility.
Data sources and study selection: A MEDLINE search (1966-November
2001) was done to identify all pertinent English-language journal
articles. A review of reference sections of the major review articles
was performed to identify additional articles. Search terms included
emergency contraception, postcoital contraception, postfertilization
effect, Yuzpe regimen, levonorgestrel, mechanism of action, Plan B. DATA
Synthesis: The 2 most common types of hormonal EC used in the US are
the Yuzpe regimen (high-dose ethinyl estradiol with high-dose
levonorgestrel) and Plan B (high-dose levonorgestrel alone). Although
both methods sometimes stop ovulation, they may also act by reducing the
probability of implantation, due to their adverse effect on the
endometrium (a postfertilization effect). The available evidence for a
postfertilization effect is moderately strong, whether hormonal EC is
used in the preovulatory, ovulatory, or postovulatory phase of the
menstrual cycle.
Conclusions: Based on the present theoretical and empirical evidence,
both the Yuzpe regimen and Plan B likely act at times by causing a
postfertilization effect, regardless of when in the menstrual cycle they
are used. These findings have potential implications in such areas as
informed consent, emergency department protocols, and conscience
clauses.
Edmund D. Pellegrino
- Conscientious persons strive to preserve moral integrity. This
requires that their external behavior be congruent with their
conscience's internal dictates about what they take to be morally
right and feel compelled to do. In our morally diverse world,
conscientious persons may come into conflict with each other and with
society's moral values. Except for the amoral sociopath, conflicts of
conscience are a regular feature of the moral life. Even for extreme
relativists, resolving these conflicts is a constant challenge. . .
Louis-Jacques van Bogaert
- Abstract: The South African Choice on Termination of
Pregnancy Act 92 of 1996 gives women the right to voluntary abortion
on request. The reality factor, however, is that five years later
there are still more 'technically illegal' abortions than legal ones.
Amongst other factors, one of the main obstacles to access to this
constitutionally enshrined human right is the right to conscientious
objection/refusal. Although the right to conscientious objection is
also a basic human right, the case of refusal to provide abortion
services on conscientious objection grounds should not be seen as
absolute and inalienable, at least in the developing world. In the
developed world, where referral to another service provider is for the
most part accessible, a conscientious objector to abortion does not
really put the abortion seeker's life at risk. The same cannot be
said in developing countries even when abortion is decriminalised.
This is because referral procedures are fraught with major obstacles.
Therefore, it is argued that the right to conscientious objection to
abortion should be limited by the circumstances in which the request
for abortion arises.