While intended primarily for medical, pharmacy and nursing students,
what follows may be of assistance to others studying for a career in
health care or practitioners already in the field.
Conflicts of conscience can arise for a variety of reasons in nursing or
medical practice, just as they do in other walks of life. However, if you
are preparing for a career in medicine, nursing, pharmacy or related fields,
you probably know that the exercise of freedom of conscience in health care
is controversial. It often generates adverse and even hostile reactions from
persons in positions of power or influence, and from colleagues, patients,
or special interest groups. If you think you could become the target of this
hostility, read on.
Those who disagree with your position will most likely do so because they
are working from beliefs and principles uncritically assimilated from the
dominant social, legal and intellectual culture. Your religious or moral
upbringing may place you, in some sense, outside this culture, but your
perspective may also reflect unexamined commitments to religious or moral
beliefs. Unless these underlying differences are exposed, ethical disputes
between you and your colleagues will be difficult to resolve.
Acknowledgement of three further points will be helpful.
First: in an important sense, everyone is a believer. Everyone acts and
lives according to some ultimate standard by which he distinguishes right
from wrong. In this respect, an atheist is as much a believer as an
observant Jew. To require that someone surrender his religious or moral
convictions and instead accept 'the ethics of the profession' does not
exclude belief; it suppresses one kind of belief and replaces it with
another. Absent the demonstrable superiority of the ethics of the
profession, there is no reason to submit to such an authoritarian demand.1,2,3
Second: the sciences that deal with material reality are not the only
sources of knowledge, and certainly do not produce what is essential for the
realization of human happiness through the correct ordering of society and
human relationships. Love, justice, mercy, solidarity, wisdom and other
virtues will make the most unscientific society a happy one, while the most
scientific society will be rendered miserable by their absence.
TThird: conscientious objection is a means by which a practitioner can
preserve his own integrity by refusing to facilitate or participate in an
immoral act. It is not a means to control the conduct of the patient or
convert patients or colleagues to one's views.
The following recommendations presume these preliminaries. They are not exhaustive.
be adapted to your circumstances, experience and personality.
As a first step, you must identify practices, procedures, or services
that may be expected of you, but to which you object for reasons of
conscience. The most common controversies centre around issues at the
beginning and end of life: abortion, contraception, euthanasia, assisted
suicide. However, the morality of artificial reproductive technology and
eugenic engineering is sharply contested, and you may also have concerns
about research on human subjects. Students in some countries may have to
consider what might be expected of them in relation to capital punishment,
torture, or coercive interrogation of persons in state custody.
Having identified morally problematic procedures or services, which you
may be able to do with little difficulty, it is not prudent to rest a claim
to conscientious objection upon a generic and undeveloped appeal to
religious belief or freedom of conscience. You must articulate the basis for
your objections. There are three reasons for this.
First: even if the law in your jurisdiction recognizes freedom of
conscience and religion, such freedoms are not unlimited in principle. Those
who want to suppress freedom of conscience among health care workers are
less likely to deny that freedom than to substantially restrict it. Thus,
you must not only be able to identify a religious or moral basis for your
objection; you must be prepared to argue that it is reasonable and possible
to accommodate you.
Second: religious believers may find that nominal co-religionists do not
share their judgement about the moral acceptability of a procedure. This can
make it more difficult to credibly assert, for example, that "Christians do
not do X" or "Muslims do not do Y", especially if the person opposing your
views has some official religious status or authority. Additional
complications arise within a denominational health care institution in this
Third: people raised within a religious, moral or cultural tradition are
more likely to live by their beliefs and principles than to analyse them. As
a result, they may find it difficult to explain or defend them when pressed,
even if those principles are solidly grounded in practical wisdom and tested
by centuries of collective experience. They may also make contradictory or
ill-founded statements when struggling to articulate their views. In
consequence, they can lose credibility with colleagues or persons in
authority, and significantly weaken arguments that might be made later in an
appeal before an academic committee or in a disciplinary hearing or court case.
Carefully consider the religious doctrines or moral principles to which you
adhere to ensure that you understand them correctly, can apply them in
practical situations and can explain them to others. As a conscientious
objector, you must develop your ability to communicate with people who do
not share your views or who actively oppose them. Listen carefully to
opposing arguments and prepare effective responses.
You must consider how you will respond when in doubt
about significant facts or moral issues, particularly when life or health is
imminently at risk.
If you wish to avoid compromising your personal
integrity, you must reflect carefully upon how to apply your
religious or moral convictions in critical situations. You must
consider how you will respond when in doubt about significant facts or moral
issues, particularly when life or health is imminently at risk.
Some people consider themselves morally culpable only if they are direct
participants in an immoral act, and do not object to referring a patient to
someone willing to do what the patient wants. Others believe that it is
immoral to facilitate a wrong by referral or other forms of assistance.
Demands for compulsory referral or other forms of indirect participation
generate much of the controversy about the exercise of freedom of conscience
in heath care. Conflicts also arise about providing some kinds of
information. You must determine, in advance, how you will approach
Religious and ethical traditions frequently offer principles or
guidelines to assist with moral reasoning. Be sure that you are aware of
them, and be prepared to look to the insights offered by other traditions to
supplement your own.
Sound moral or ethical reasoning depends upon a complete and accurate
grasp of relevant facts. For example: one cannot discuss the morality of
embryonic stem cell research without a correct understanding of human
embryology, and conscientious objection to euthanasia ought to be informed
by adequate knowledge of palliative care.6
You may not be able to master all of the literature on a given subject,
but you should take care to inform yourself fully about critical issues or
points of contention. Demonstrate appropriate academic discipline and
intellectual honesty in your adherence to or rejection of research findings.
Academic discipline requires an ability to distinguish between what lies
within the province of science and what lies elsewhere. "Personhood" can
have distinctive philosophical or legal meanings, but it is not a scientific
concept at all. Whether or not something "ought" to be done is a subject for
philosophy, religion, or ethics - not science.7
It is quite appropriate to challenge moral reasoning that is based upon
erroneous science. But you should not tolerate bullying by professors,
preceptors or colleagues who attempt to dismiss your moral convictions on
the specious grounds that they are 'unscientific'; their own moral
convictions are equally unscientific, and cannot be otherwise.
Universities ought to have fairly extensive policies on evaluations of
academic progress and of preceptorships. These policies should set out, in
general terms, how the evaluations are to be done and how they may be
appealed. A description of the appeal process ought to include the manner in
which an appeal is to be launched, the stages through which it progresses,
and the times within which each stage must be completed. Ideally, the
policies will also set out the composition of the various committees or
bodies hearing the appeal and the rights of students with respect to
representation at the hearings. You should review these policies and ensure
that you understand them and know how to access them.
Professional colleges and associations have codes of ethics and policies
that touch on issues of concern to conscientious objectors. For example: the
Canadian Medical Association does not require referral for morally
controversial procedures. Obtain copies of these policies and study them.
Pay particular attention to the policies of regulatory bodies like Colleges
of Physicians, which have disciplinary and licensing authority, but do not
ignore the policies of specialist associations that may have considerable
influence in setting standards of care.
You cannot be expected to master human rights
jurisprudence, but you should read the statutes governing human rights law
in your jurisdiction and make copies of relevant sections.
You cannot be expected to master human rights jurisprudence, but you
should read the statutes governing human rights law in your jurisdiction and
make copies of relevant sections. Be aware that statutes are interpreted by
courts in decisions that are reported in "case law," and that a full
understanding of the law requires knowledge of these cases. You are unlikely
to have time for that kind of research. If a question arises about the
application of part of a human rights statute to your case, you might begin
by seeking help from a friend who is studying law. You might also be able to
consult a paralegal service provided by a university law school, unless you
believe that it may be unsympathetic or even hostile. If the issue is
important or complicated, consult a lawyer.
Many jurisdictions now have freedom of information statutes that give
citizens the right to access any information about them held by state or
institutional authorities. Depending upon the wording of a statute, such a
law might be used to force the university to disclose any information it has
in its files concerning you, including 'confidential' internal memos and
e-mails. If there is a freedom of information law in your jurisdiction,
obtain a copy of it and find out whether or not it applies to the
university. You may be able to get this information easily if the university
has a privacy or freedom of information officer responsible for complying
with requests for disclosure.
Having identified your concerns, you must be alert to any suggestion or
inference that someone who can adversely affect your professional or
educational standing has taken unfavourable notice of your views. The first
indication could be as blatant as an expletive-filled insult, or as
subtle as a questioning glance. You must be on the lookout for any sign of
approaching difficulty in order to take all appropriate steps to protect
yourself. On the other hand, being alert does not mean being
habitually suspicious or distrustful. Caution is appropriate; anxiety
or fear are not.
Some objectors encounter problems primarily because of the way they
communicate with patients, colleagues or others. If it is necessary to
explain your position, do so in a way that refers to your own moral
responsibility, not that of your patient or colleague. Some
explanations or terminology may make others uncomfortable, but may be
required to fully articulate your position. However, whenever
possible, avoid expressions
that impute wrongdoing to others or that might come across as "preaching".
You should not become hypersensitive to what others
might be thinking, since that will only cause needless anxiety. On the other
hand, one should not ignore clear signals that something is amiss.
Conscientious objection is likely to make colleagues who do not share
your views uncomfortable because it implies that what they are doing is
wrong. It is unwise to challenge their moral judgement directly because this
will increase their discomfort and provoke hostilty.
If you perceive discomfort, take note of it: "You seem
troubled/ disturbed/surprised." Invite dialogue: "Have I offended
This approach expresses concern for others and respect for their
sensibilities, while providing an opportunity for discussion.
You should not become hypersensitive to what others might be thinking;
that will only cause needless anxiety. On the other hand, one should not
ignore clear signals that something is amiss. Your ability to read those
signals will depend upon how well you know the other person and your own
experience. If in doubt, remain silent, but make a note of the incident. If
a problem is developing, your notes will probably make it apparent to you in
In addition to discomfort, you may encounter a belligerent challenge,
contempt or condescension. If you are taken by surprise or find yourself
flustered, no harm is done by admitting the fact and suggesting that you and
your interlocutor should make time for an uninterrupted chat. If it is
possible to make time for it then and there, do so. However, don't rush into
what might prove to be a contentious discussion simply because you feel the
need to counter an offensive or ill-timed remark. You will do yourself and
your colleague a favour by giving yourself even a few minutes to reflect and
The notion of working together with your critics is
important. The goal is authentic and respectful communication, even if it
involves serious argument and fundamental disagreements.
Resist the urge to explain or defend yourself. Instead, ask your
interlocutors to explain their concerns. Listen carefully, and ask questions,
not to challenge their views, but to clarify the issues and identify any
unexamined presuppositions that underlie their thinking. This
will give you the opportunity to settle some butterflies, organize your own
thoughts and build your confidence. It should also diminish any antagonism
felt by fair-minded critics, since they will see that you are listening to them and
taking their concerns seriously. They may even feel that he is making a
significant impact on you.
Nonetheless, the most important reason to begin by listening is that you
cannot respond effectively if you do not know what case you have to answer.
You will only exasperate colleagues if you don't understand them or argue from
incorrect assumptions about what they know or believe. Let them tell you
what they think.
Identify points of agreement and points of contention, and work together
The notion of working together with critics is important. The goal is
authentic and respectful communication, even if it involves serious argument
and fundamental disagreements.
If you are uncertain about how to reply to facts or an argument presented
by your critics, you should simply admit it and promise to continue the
discussion after you have had time to think further about it or research the
problem. Offer your critics the same courtesy, unasked for, if need be. There
is no need to resolve everything at once. In fact, it may prove difficult to
resolve even preliminary matters in the first encounter.
When serious discussion generates enthusiasm for enquiry you may find
yourself 'thinking out loud' as you attempt to tease out the strands of your
critics' argument or consider the significance of facts they raise. When the
issue is related to you conscientious convictions, this ordinarily harmless
practice can have undesirable consequences, especially in conversation with
persons in authority. If you sincerely say "A", and, upon reflection, later
revise "A" to "B," you may be accused of duplicity or irrationality, or
characterized as someone who doesn’t know what he believes.
When you have to think out loud in serious conversations with preceptors
or colleagues about ethical issues, be sure to tell them that is what you
are doing so that they will recognize the provisional nature of your
comments. If you realize you need to reflect more carefully before
continuing such a conversation, thoughtful people will accept that, and
critics will have no just cause for complaint. Better to consider an issue
privately or with the assistance of an ally than to speak to it prematurely.
Make detailed notes each time you encounter criticism or questions about
your views, even if the incident seems minor or unimportant. The real
significance of a question in September may not become apparent
until after a clash in February. You will never regret recording
information, but you will certainly regret not having done so.
Do not rely on your memory even in the case of encounters that you are
sure you will never forget. An appeal to an academic committee may not be
heard for months; cross-examination before a court or human rights tribunal
could come two years afterward. You will not accurately recall what
was said unless you make notes of it at the time. Moreover, if the other
parties to the incident made notes and you did not, it is probable that
their accounts of what took place will be given much greater weight than
If you cannot make detailed notes at the time or immediately afterward,
make what notes you can, and expand them at the first reasonable opportunity
that day. See
Making Notes: Documenting Workplace Conflicts for detailed discussion of note taking.8
Although note-making is obviously useful if a problem actually occurs, it
can also help you to navigate uncertain terrain with greater confidence.
You cannot know what will happen in future. Rather than worry about what
might happen, make notes and put the matter aside. As time passes,
your notes (or lack of them) may well confirm that you have nothing to fear.
On the other hand, they may establish a pattern indicative of a developing
problem and help you respond effectively. In either case, you will
have done something useful by making notes and avoided unnecessary and
You should obtain a copy of any document referring to your situation, including media reports, social media comments and internet
postings. Relevant social media postings should be copied as soon as
they are found, as they may soon be deleted if the originator realizes you
may find them useful. Techniques for capturing on-line information include:
- saving web pages as MHT files
- taking screen shots and saving them as image files
- printing web pages
- printing/converting web pages to pdf
- downloading and saving files
Incorporate the date and time of the document as the first part of the
file name in the form YYYY-MM-DD-HH-MM. This will facilitate automatic
chronological filing of documents that may not have been found in
chronological order. Add the source URL and date and time it was
accessed in the document if that is not done automatically by the
access/save process, or otherwise make note of it. This information
will be important if it is necessary to cite the documents.
If presented with a formal document for your acknowledgement in relation
to freedom of conscience, such as a memo, caution, reprimand or
evaluation, first consider whether you should seek legal or other
professional advice before signing or acknowledging it as requested.
If you disagree with the document in whole or in part, but decide to sign or
acknowledge it, include with your signature or acknowledgement a statement
of your disagreement.
In all cases, initial each page. When a significant part of a page is blank, strike a line from the last
line to the bottom of
the page and initial there. Strike through and initial blank sections of a
document. These precautions will prevent changes being made to the
document after you have seen it. If you are later presented with a
different document, the differences between the two may be significant.
Request copies of such documents. If university authorities refuse,
politely advise them that you believe that you are entitled to it because it
is your information. Explain that you would like to avoid legal action to
compel its release. If this has no effect, consult university policies,
access to information legislation and contacts within your profession. If
your university has a law school you may be able to access some form of
para-legal assistance through senior students there; otherwise, see a
lawyer. If you are persistent and methodical you are likely to find a way
to convince or compel the university to comply with your request.
It is important to connect with like-minded colleagues in the university
so that you can discuss problems as they arise. It is even more important to
remain in contact with sympathetic people already active in your chosen
profession. Their experience and knowledge of its administration will
likely be invaluable if you run into trouble. Seek their advice and
assistance as soon as you encounter any significant criticism. When
approached by a student in difficulty, the Protection of Conscience Project
will immediately facilitate contact between the student and professionals
who are willing to assist.
If you encounter significant opposition, criticism, unfair evaluations or other forms
of repression from university authorities, professors or preceptors, do
not assume that you will be able to work things through on your own,
especially if you have to launch an academic appeal. Seek legal advice. Failure in a key preceptorship or subject may nullify everything else you
have accomplished. The harm done by losing an appeal at the first level may
prove very difficult to undo in subsequent appeals or even through civil
Anti-religious secularists often try to banish religion from the public
square by claims that religious beliefs are intrinsically divisive and
encourage differences that lead to violence. The example of friendly
collaboration in matters of mutual interest among people of different
faiths, disciplines and backgrounds provides a practical and powerful
counter-witness to such assertions. This is one of the reasons that the
Project Advisory Board consists of scholars from different disciplines
and different faiths, including Judaism, Catholic and Protestant
Christianity and Islam.
Long before a crisis looms you should seek the fellowship of students and
professionals from other religious traditions (or none) who have a common
interest in securing freedom of conscience in health care. You may be
surprised to find that someone from a completely different faith and culture
is more supportive of your views than a co-religionist who lives down the
If your university has a medical school, it may well have a law school and
departments of philosophy and political science. You may find friends and
supporters in all of these faculties.
Be cautious if you are approached by the media, as media reports may well
complicate resolution of your difficulty. The 'friendly' reporter may skewer
you, or his editor may mangle story by cutting or changing it for
publication . More commonly, the media often highlight controversy (conflict
sells) and polarize opinion by simplistic reporting that fails to make
appropriate distinctions or identify important issues. 'Advocacy journalism'
from any perspective is potentially problematic; 'friendly fire' kills, too.
Television and radio interviews present particular problems because a
lengthy interview may yield a five second sound bite unrepresentative of the
discussion. These 'bites' can be sandwiched between other visuals or
commentary to produce unpleasantly surprising results. It is also
extraordinarily difficult to successfully convey a philosophical or moral
argument on television because pictures - the very essence of TV journalism
- are better at communicating emotion than logical thought.
You should not agree to an interview unless you are quite sure how much
of the case you are prepared to discuss. If there are things that you don't
want to talk publicly about, be sure that you can explain the reason(s) for
your reticence to the reporter in advance. For example: you might think it
safe to explain the principled basis for your objections, but not to discuss
what took place between you and your colleague, preceptor or patient because
of a pending review or hearing. If you attempt to pick and choose the
questions you will answer, it is likely to appear that you have something to
hide or are unsure of yourself. Do not answer a question with, "No
comment." If you choose not to answer a question, explain why you cannot
Do not attempt to direct reporters as to what angle they should take in a
story or what they should write. Never ask a journalist to let you
review a story before publication. Most will refuse, many will have
nothing more to do with you, and not a few will make you the target rather
than the subject of a column or editorial.
Reporters often electronically record interviews, but are
not obliged to notify you of the fact. Don't ask if you are being recorded
(the question suggests you have something to hide). Assume that any
conversation with a reporter is being taped.
Reporters often electronically record interviews, but are not obliged to
notify you of the fact. Don't ask if you are being recorded (the question
suggests you have something to hide). Assume that any conversation with a
reporter is being taped. You may record your conversations and interviews
with reporters, but always tell them you are doing so. One journalist
consulted by the Project commented, "Your recording will keep an honest
reporter honest, and scare the dishonest one straight."
If surprised by a call from the media, take the reporter's name and contact
information and call back after you have settled your butterflies and
considered your position. If you are not certain that you should speak to
the media, do not do so. An unsolicited request for an interview can be
courteously turned aside with the explanation that you hope to resolve the
problem through the channels open to you, and you don't wish to complicate
matters by speaking publicly. A good reporter will accept this, but will
also try - politely - to get you to say something, perhaps in response to a
hypothetical question. Don't take the bait. Take the reporter's name and
contact information and explain that you will call should you decide to
speak publicly later on.
If, after an interview, you realize that you have made an error or
believe that you didn't express yourself clearly, call the reporter to
clarify your comments or correct your mistake; better to be considered
sincerely mistaken than carelessly ignorant.
All of these considerations apply to questions posed by reporters in
emails, though emailed responses are less likely to be misquoted or
misrepresented, and may actually be a good way of communicating complex
information. As with live interviews, however, assume that anything
you say to a reporter may appear on the front page of a national newspaper.
Nothing is ever "off the record."
Beware of suggestions that you should 'go public'.
Speaking to the media to garner sympathy or support for your position should
only be attempted after careful consideration and consultation; it is
Beware of suggestions that you should 'go public'. Speaking to the media
to garner sympathy or support for your position should only be attempted
after careful consideration and consultation; it is normally inadvisable.
Fear that you might launch a media initiative may encourage compromise by
your opposition; a failed media initiative will only solidify their
Conscientious objectors usually form a minority within a profession and
the public at large, so even if the media take up the story and people take
notice, it is likely to generate as much opposition as support. Moreover,
opponents of freedom of conscience in health care tend to be well-funded and
well-connected with media, government and the professions. Media attention
may cause them to launch a campaign against you, and you may be hard-pressed
to counter it.
Another point to consider is that the media, politicians and many members
of the professions tend to be dismissive of anything to which a pro-life
label is attached. If your objection concerns a pro-life issue, you will be
able to secure the support of the pro-life community, but that may carry
very little weight with the wider public or those handling your case, and
may actually inflame prejudice against you.
If there is an internal review or appeal process available to you, that
is the first place to make your case. You are likely to undermine your
credibility if you appear to be seeking a verdict through the media rather
than in the proper forum. Media reports, especially those that contain
misquotes or other inaccuracies, can come back to haunt you during an
academic appeal or judicial proceeding. You may find yourself being asked to
explain something that you did not say, or (worse) something that you did
say that was reported out of context, or (worst of all) something you regret
having said that was not only accurately reported, but captured in an audio
Despite all of these arguments against 'going public', there are
times when it may be productive to do so. For example: if the university
were to refuse to give you a copy of your evaluation or some similarly
important document, it is likely that most students would support your right
of access, even if they disagreed with your ethical stance. In that case,
however, one would highlight the issue of freedom of information, not
Of course, not all media are hostile or unfair, and sometimes media
attention can favourably influence the course of events. By all means,
collaborate with others to develop a media strategy, but keep it in reserve
until it is clear that it can be implemented safely and effectively. It
might be prudent to first break the story with potentially sympathetic
outlets or reporters who (one hopes) will report it fairly and accurately.
However, once you 'go public,' even with someone you think trustworthy, you
will have no control over how the media handle the story. That is one of the
reasons your opponents may be willing to compromise to avoid public
exposure. They can't control the media, either.
If you are in serious difficulty, download and complete the
Complainant Worksheet on the Project website.9 It is meant to help you to obtain and organize information
pertaining to your case. Completing the Worksheet before you see a lawyer or
other professional will provide you with much of the information he may
require in order to assess your position.
Use the Project website to obtain arguments and information relevant to
your situation. Contact the
Project Administrator if you cannot find what you need, or if you are
encountering coercion or discrimination. Every effort will be made to
provide you with support and assistance. The service is limited, but it is
Even if it had the resources, the Project has no standing to intervene
with university authorities or appear before a tribunal hearing your case,
but it may be possible to prepare a
report on the matter. The report will be given to you, to be used in
accordance with the rules of evidence in your jurisdiction and as you or
your counsel think best. It will not be further disseminated without your
- A report is only as good as the information upon which it is based.
- The preparation of a report is a painstaking and time-consuming
process. One such report runs to 21 single spaced pages, with an
additional 34 pages of appendices and 126 end notes. If a report is
needed, all available information and documents should be forwarded to
the Project as soon as possible.
- A Project report is not polemical whitewash. If it is to stand
scrutiny, it must be based upon the evidence submitted. It may,
therefore, include comments unfavourable to the objector.
This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
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