Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any action (...) contrary to their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care. (shrink)

Certain health care services and goods, although legal and often generally accepted in a society, are by some considered morally problematic. Debates on conscientious objection in health care try to resolve whether and when physicians, nurses and pharmacists should be allowed to refuse to provide medical services and goods because of their ethical or religious beliefs. These debates have most often focused on issues such as how to balance the interests of patients and health care professionals, and the compatibility (...) of conscientious objection with professional obligations, but it is also possible to think about conscientious objection in terms of how to respond to moral disagreement and the requirements of liberal neutrality. (shrink)

This article asks whether firms should exempt employees when they object to elements of their work that go against their conscience. Fairness requires that we follow the rules of an organization we have joined voluntarily only if these rules express mutual advantage. In corporations, I argue that subordination and exemption provides for mutual advantage better than subordination plus right of exit. This is because agents want to protect their conscientious convictions, even in hierarchical organizations geared towards efficient preference satisfaction. (...) Thus exemptions should be granted in unforeseeable circumstances, provided the costs are limited. (shrink)

What is conscientious objection? -- Should conscientious objectors be accommodated? -- Assessing objectors' beliefs and reasons -- Accommodation and conscientious provision.

In this paper, we argue that providers who conscientiously refuse to provide legal and professionally accepted medical care are not always morally required to refer their patients to willing providers. Indeed, we will argue that refusing to refer is morally admirable in certain instances. In making the case, we show that belief in a sweeping moral duty to refer depends on an implicit assumption that the procedures sanctioned by legal and professional norms are ethically permissible. Focusing on examples of female (...) genital cutting, clitoridectomy and ‘normalizing’ surgery for children with intersex traits, we argue that this assumption is untenable and that providers are not morally required to refer when refusing to perform genuinely unethical procedures. The fact that acceptance of our thesis would force us to face the challenge of distinguishing between ethical and unethical medical practices is a virtue. This is the central task of medical ethics, and we must confront it rather than evade it. There are no data in this work. (shrink)

Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act (...) on one’s conscience. Second, I sketch an account of the basis of the medical and pharmacy professions’ responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the “conventional compromise” as a reasonable accommodation to conflicts between these professions’ responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: “Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?”. (shrink)

In a recent article in this journal, Savulescu and Schuklenk defend and extend their earlier arguments against a right to medical conscientious objection in response to criticisms raised by Cowley. I argue that while it would be preferable to be less accommodating of medical conscientious than many countries currently are, Savulescu and Schuklenk's argument that conscientious objection is ‘simply unprofessional’ is mistaken. The professional duties of doctors should be defined in relation to the interests of patients and (...) society, and for reasons set out in this article, these may support limited accommodation of conscientious objection on condition that it does not impede access to services. Moreover, the fact that conscientious objection appears to involve unjustifiable compromise from the objector's point of view is not a reason for society not to offer that compromise. Arguing for robust enforcement of the no-impediment condition, rather than opposing conscientious objection in principle, may be a more effective way of addressing the harms resulting from an over-permissive conscientious objection policy. (shrink)

Religion is often singled out for special legal treatment in Western societies - which raises an important question: what, if anything, is special about religious conscience beliefs that warrants such special legal treatment? In this paper, I will offer an answer to this specialness question by investigating the relationship between religious conscientious objections and their insulation from relevant evidence. I will begin my analysis by looking at Brian Leiter’s arguments that religious beliefs are insulated from evidence and not worthy (...) of special legal treatment as a result. I will argue that he fails to show that religious conscience beliefs are both in principle responsive to empirical evidence and in practice typically more insulated from this evidence than secular conscience beliefs. If I am right about this, then Leiter fails to answer the “central puzzle” of his recent book and fails to sufficiently distinguish the religious conscience from the secular conscience. Second, I will look at whether or not it is plausible to understand the religious conscience as insulated from other forms of evidence. Following the research of social-psychologist Jonathan Haidt, I will argue that, typically, both forms of conscience seem to be similarly insulated from moral argumentation. I will also show that, while it seems as though the religious conscience usually draws from a larger set of moral values when compared to the secular conscience, this should make no legal difference overall. To conclude, I will explain that the arguments in this paper can be understood as evidence in support of an egalitarian response to religion’s specialness. (shrink)

Conscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis.

The literature on conscientious objection in medicine presents two key problems that remain unresolved: Which conscientious objections in medicine are justified, if it is not feasible for individual medical practitioners to conclusively demonstrate the genuineness or reasonableness of their objections? How does one respect both medical practitioners’ claims of conscience and patients’ interests, without leaving practitioners complicit in perceived or actual wrongdoing? My aim in this paper is to offer a new framework for conscientious objections in medicine, (...) which, by bringing medical professionals’ conscientious objection into the public realm, solves the justification and complicity problems. In particular, I will argue that: an “Uber Conscientious Objection in Medicine Committee” —which includes representatives from the medical community and from other professions, as well as from various religions and from the patient population—should assess various well-known conscientious objections in medicine in terms of public reason and decide which conscientious objections should be permitted, without hearing out individual conscientious objectors; medical practitioners should advertise their conscientious objections, ahead of time, in an online database that would be easily accessible to the public, without being required, in most cases, to refer patients to non-objecting practitioners. (shrink)

Most proponents of conscientious objection accommodation in medicine acknowledge that not all conscientious beliefs can justify refusing service to a patient. Accordingly, they admit that constraints must be placed on the practice of conscientious objection. I argue that one such constraint must be an assessment of the reasonability of the conscientious claim in question, and that this requires normative justification of the claim. Some advocates of conscientious object protest that, since conscientious claims are a (...) manifestation of personal beliefs, they cannot be subject to this kind of public justification. In order to preserve an element of constraint without requiring normative justification of conscientious beliefs, they shift the justificatory burden from the belief motivating the conscientious claim to the condition of the patient being refused service. This generally involves a claim along the lines that conscientious refusals should be permitted to the extent that they do not cause unwarranted harm to the patient. I argue that explaining what would constitute warranted harm requires an explanation of what it is about the conscientious claim that makes the harm warranted. ‘Warranted’ is a normative operator, and providing this explanation is the same as providing normative justification for the conscientious claim. This shows that resorting to facts about the patient’s condition does not avoid the problem of providing normative justification, and that the onus remains on advocates of conscientious objection to provide normative justification for the practice in the context of medical care. (shrink)

The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court's decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare providers (...) on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women's rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience. (shrink)

The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court's decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare providers (...) on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women's rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience. (shrink)

The Australian state of Victoria legalised voluntary assisted dying in June 2019. Like most jurisdictions with legalised VAD, the Victorian law constructs physicians as the only legal providers of VAD. Physicians with conscientious objection to VAD are not compelled to participate in the practice, requiring colleagues who are willing to participate to transact the process for eligible applicants. Physicians who provide VAD because of their active, moral and purposeful support for the law are known as conscientious participants. (...) class='Hi'>Conscientious participation has received scant attention in the bioethics literature. Patient access to VAD is contingent on the development of a sufficient corpus of conscientious participants in permissive jurisdictions. This article reports the findings of a small empirical study into how some Victorian physicians with no in-principle opposition towards the legalisation of VAD, are ethically orientating themselves towards the law, in the first 8 months of the law’s operation. It finds that in-principle-supportive physicians employ bioethical principles to justify their position but struggle to reconcile that approach with the broader medical profession’s opposition. This study is part of the first tranche of empirical research emerging from Australia since the legalisation of VAD in that country for the first time in over 20 years. (shrink)

Conscientious objection in health care is a form of compromise whereby health care practitioners can refuse to take part in safe, legal, and beneficial medical procedures to which they have a moral opposition (for instance abortion). Arguments in defense of conscientious objection in medicine are usually based on the value of respect for the moral integrity of practitioners. I will show that philosophical arguments in defense of conscientious objection based on respect for such moral integrity are extremely (...) weak and, if taken seriously, lead to consequences that we would not (and should not) accept. I then propose that the best philosophical argument that defenders of conscientious objection in medicine can consistently deploy is one that appeals to (some form of) either moral relativism or subjectivism. I suggest that, unless either moral relativism or subjectivism is a valid theory—which is exactly what many defenders of conscientious objection (as well as many others) do not think—the role of moral integrity and conscientious objection in health care should be significantly downplayed and left out of the range of ethically relevant considerations. (shrink)

This book argues that a conscientiously objecting medical professional should receive an exemption only if the grounds of an objector's refusal are reasonable. It defends a detailed, contextual account of public reasonability suited for healthcare, which builds from the overarching concept of Rawlsian public reason. The author analyzes the main competing positions and maintains that these other views fail precisely due to their systematic inattention to the grounding reasons behind a conscientious objection; he argues that any such view is (...) plausible to the extent that it mimics the 'reason-giving requirement' for conscience objections defended in this work. Only reasonable objections can defeat the prior professional obligation to assign primacy to patient well-being, therefore one who refuses a patient's request for a legally available, medically indicated, and safe service must be able to explain the grounds of their objection in terms understandable to other citizens within the public institutional structure of medicine. The book further offers a novel policy proposal to deploy the Reasonability View: establishing conscientious objector status in medicine. It concludes that the Reasonability View is a viable and attractive position in this debate. A New Theory of Conscientious Objection in Medicine: Justification and Reasonability will be of interest to researchers and advanced students working in bioethics, medical ethics, and philosophy of medicine, as well as thinkers interested in the intersections between law, medical humanities, and philosophy. (shrink)

Aaron Ancell and Walter Sinnott-Armstrong (A&SA) propose a pragmatic approach to problems arising from conscientious objections in healthcare. Their primary focus is on private healthcare systems like that in the United States. A&SA defend three claims: (i) many conscientious objections in healthcare are morally permissible and should be lawful, (ii) conscientious objections that involve invidious discrimination are morally impermissible, but (iii) even invidiously-discriminatory conscientious objections should not always be unlawful, as there is a better way to (...) protect patient rights. Pursuant to (iii), A&SA propose a framework that legally allows discriminatory conscientious objections, but that shifts the financial costs associated with such objections from patients to the clinics that employ doctors who discriminate against patients. Though their proposal is controversial, it has attractive features, and merits further discussion. In this paper, I remain neutral on the third claim A&SA advance in support of their proposal, but point out a problem with the two first claims. In the light of my criticisms, I propose to modify their proposal so that costs are shifted to clinics in a broader range of cases. (shrink)

It is argued that the primary aim of institutional management is to protect the moral integrity of health professionals without significantly compromising other important values and interests. Institutional policies are recommended as a means to promote fair, consistent, and transparent management of conscience-based refusals. It is further recommended that those policies include the following four requirements: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) Conscience-based (...) refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on colleagues, supervisors, department heads, other administrators, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. Formal review may not be required in all cases, but when it is appropriate, several recommendations are offered about standards and the review process. A key recommendation is that when reviewing an objector’s reasons, contrary to what some have proposed, it is not appropriate to adopt an adversarial approach modelled on military review boards’ assessments of requests for conscientious objector status. According to the approach recommended, the primary function of reviews of objectors’ reasons is to engage them in a process of reflecting on the nature and depth of their objections, with the objective of facilitating moral clarity on the part of objectors rather than enabling department heads, supervisors, or ethics committees to determine whether conscientious objections are sufficiently genuine. (shrink)

Conscientious refusal involves decisions by healthcare workers, on grounds of their conscience, to refuse to provide legal, professionally permissible and safe health interventions to patients. Conscientious provision involves decisions by healthcare workers, also on grounds of conscience, to provide safe and beneficial healthcare to patients that is prohibited by law or policy. Some bioethicists believe that the moral issues governing both are identical, and that if one permits conscientious refusals, one should also permit conscientious provisions. This (...) article argues that this assumption of symmetry is incorrect. To demonstrate this, it does the following: first, it establishes why it matters that we understand the difference between them; second, it describes three recent cases of conscientious provision in Canadian healthcare to help characterize its nature and scope; third, it situates these cases in a socio-economically nuanced analysis of the role of the conscientious provider under conditions or privilege and oppression; finally, it applies insights from the cases and the intersectional analysis to common criticisms of conscientious refusal to reinforce the fundamental asymmetries between conscientious refusal and conscientious provision. (shrink)

A recent focus of the debate on conscientious objection in healthcare is the question of whether practitioners should have to justify their refusal to perform certain functions. A recent article by Cowley addresses a practical aspect of this controversy, namely the question of whether doctors claiming conscientious objector status in relation to abortion should be required, like their counterparts claiming exemption from military conscription, to defend their claim before a tribunal. Cowley argues against the use of tribunals in (...) the medical case, on the grounds that there are likely to be fewer unjustified claims to conscientious objection in this context than in the military, and that in any case tribunals will not be an effective way of distinguishing genuine and false cases. I reject these arguments and propose a different conception of the role of a medical conscientious objection tribunal. (shrink)

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. (shrink)

In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician’s professional obligations (the “incompatibility thesis”). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal (...) morality (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician’s professional obligations unequivocally supports the incompatibility thesis. (shrink)

Is conscientious objection necessarily incompatible with the role and duties of a healthcare professional? An influential minority of writers on the subject think that it is. Here, we outline...

Here we respond to Shaw et al., and show why the application of Conscientious Objection cannot be dismissed from cases of organ donation, where the donor is presumed to be dead.

Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience‐based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. (...) It is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented. (shrink)

Although some healthcare professionals have the legal right to conscientiously object to authorise or perform certain lawful medical services, they have an associated duty to provide the patient with enough information to seek out another professional willing to authorise or provide the service (the ‘duty to refer’). Does the duty to refer morally undermine the professional's conscientious objection (CO)? I narrow my discussion to the National Health Service in Britain, and the case of a general practitioner (GP) being asked (...) by a pregnant woman to authorise an abortion. I will be careful not to enter the debate about whether abortion should be legalised, or the debate about whether CO should be permitted—I will take both as given. I defend the objecting GP's duty to refer against those I call the ‘conscience absolutists’, who would claim that if a state is serious enough in permitting the GP's objection in the first place (as is the UK), then it has to recognise the right to withhold any information about abortion. (shrink)

This essay offers a revisionist defense of classical utilitarianism from an infamous objection to it, which is derived from American science fiction writer, Ursula Le Guin’s, short story, “The Ones Who Walk Away from Omelas.” To that effect, the reply takes inspiration from Le Guin and John Stuart Mill in appealing to the natural law theoretical concept of conscience. I argue that a conscientious utilitarian ethic can escape Le Guin’s objection more satisfactorily than other popular utilitarian ethics. Along the (...) way, this essay discusses at length conscience and its place in moral epistemology, both as it occurs in the natural law tradition and in Mill. The natural law account of conscience is defended and Mill’s account is critiqued. Consequently, this paper also provides an interesting synthesis of utilitarianism with natural law ethics. (shrink)

Background:The concept of conscientious objection is well described; however, because of its nature, little is known about real experiences of nursing professionals who apply objections in their practice. Extended roles in nursing indicate that clinical and value-based dilemmas are becoming increasingly common. In addition, the migration trends of the nursing workforce have increased the need for the mutual understanding of culturally based assumptions on aspects of health care delivery.Aim:To present (a) the arguments for and against conscientious objection in (...) nursing practice, (b) a description of current regulations and practice regarding conscientious objection in nursing in Poland and the United Kingdom, and (c) to offer a balanced view regarding the application of conscientious objection in clinical nursing practice.Design:Discussion paper.Ethical considerations:Ethical guidelines has been followed at each stage of this study.Findings:Strong arguments exist both for and against conscientious objection in nursing which are underpinned by empirical research from across Europe. Arguments against conscientious objection relate less to it as a concept, but rather in regard to organisational aspects of its application and different mechanisms which could be introduced in order to reach the balance between professional and patient’s rights.Discussion and conclusion:Debate regarding conscientious objection is vivid, and there is consensus that the right to objection among nurses is an important, acknowledged part of nursing practice. Regulation in the United Kingdom is limited to reproductive health, while in Poland, there are no specific procedures to which nurses can apply an objection. The same obligations of those who express conscientious objection apply in both countries, including the requirement to share information with a line manager, the patient, documentation of the objection and necessity to indicate the possibility of receiving care from other nurses. Using Poland and the United Kingdom as case study countries, this article offers a balanced view regarding the application of conscientious objection in clinical nursing practice. (shrink)

The Swedish solution to the legal handling of professional conscientious refusal in healthcare is described. No legal right to conscientious refusal for any profession or class of professional tasks exists in Sweden, regardless of the religious or moral background of the objection. The background of this can be found in strong convictions about the importance of public service provision and related civic duties, and ideals about rule of law, equality and non-discrimination. Employee's requests to change work tasks are (...) handled on a case-by-case basis within the frames of labour law, ensuring full voluntariness, and also employer's privilege regarding the organisation and direction of work, and duties of public institutions to provide services. Two complicating aspects of this solution related to the inclusion of ‘alternative medical’ service providers in a national health service, and professional insistence on conscientious refusal rights to accept legalised assisted dying are discussed. The latter is found to undermine the pragmatic reasons behind recent attempts by prolife groups to challenge the Swedish solution related to legal abortion in courts. (shrink)

Some authors argue that it is permissible for clinicians to conscientiously provide abortion services because clinicians are already allowed to conscientiously refuse to provide certain services. Call this the symmetry thesis. We argue that on either of the two main understandings of the aim of the medical profession—what we will call “pathocentric” and “interest‐centric” views—conscientious refusal and conscientious provision are mutually exclusive. On pathocentric views, refusing to provide a service that takes away from a patient's health is professionally (...) justified because there are compelling reasons, based on professional standards, to refuse to provide that service (e.g., it does not heal, and it is contrary to the goals of medicine). However, providing that same service is not professionally justified when providing that service would be contrary to the goals of medicine. Likewise, the thesis turns out false on interest‐centric views. Refusing to provide a service is not professionally justified when that service helps the patient fulfill her autonomous preferences because there are compelling reasons, based on professional standards, to provide that service (e.g., it helps her achieve her autonomous preferences, and it would be contrary to the goals of medicine to deny her that service). However, refusing to provide that same service is not professionally justified when refusing to provide that service would be contrary to the goals of medicine. As a result, on either of the two most plausible views on the goals of medicine, the symmetry thesis turns out false. (shrink)

This is part of a symposium on conscientious objection and religious freedom inspired by the US Catholic Church's claim that being forced to pay for health insurance that covers abortions (the effect of 'Obamacare')is the equivalent of forcing pacifists to fight. This article takes issue with this claim, and shows that while it would be unjust on democratic principles to force pacifists to fight, given their willingness to serve their country in other ways, there is no democratic objection to (...) forcing those who believe abortion to be murder to pay for health insurance coverage that includes abortion. (shrink)

: The standard bioethics account is that respecting patient autonomy means ensuring patients make their own decisions. In fact, respecting patient autonomy often has more to do with the overall shape and meaning of patients' health care regimes, and sometimes, at least, patients will very reasonably defer to medical authority.

A key question has been underexplored in the literature on conscientious objection: if a physician is required to perform ‘medical activities,’ what is a medical activity? This paper explores the question by employing a teleological evaluation of medicine and examining the analogy of military conscripts, commonly cited in the conscientious objection debate. It argues that physicians (and other healthcare professionals) can only be expected to perform and support medical acts – acts directed towards their patients’ health. That is, (...) physicians cannot be forced to provide or support services that are not medical in nature, even if such activities support other socially desirable pursuits. This does not necessarily mean that medical professionals cannot or should not provide non-medical services, but only that they are under no obligation to provide them. (shrink)

This paper follows on from a brief debate about the role of conscientious objection in healthcare, where the issue arose as to whether conscientious objection is (or can) be a tool of resistance against systemic injustice. The paper contributes to this debate by highlighting that some authors generally opposed to conscientious objection in healthcare have shown some support to this idea. Perhaps if there is one area in which all can agree, it is that in healthcare (...) class='Hi'>conscientious objection should be allowed so as to prevent cases of systemic injustice. (shrink)

Most discussions of conscientious objection in healthcare assume that the objection is universal: a doctor objects to all abortions. I want to investigate selective objections, where a doctor objec...

Catholic doctrine’s strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that (...) confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials. (shrink)

Robert Card’s “Reasonability View” is a significant contribution to the debate over the place of conscientious objection in health care. In his view, conscientious objections can only be accommodated if the grounds for the objection meet a reasonability standard. I identify inconsistencies in Card’s description of the reasonability standard and argue that each version he specifies is unsatisfactory. The criteria for reasonability that Card sets out most frequently have no clear underpinning principle and are too permissive of immoral (...) objections. Card has also claimed that petitioners must justify their positions with Rawlsian public reason. I argue that, although the resulting reasonability standard is principled, it is overly restrictive. I also show that a reasonability standard built on Rawls’ more lenient conception of reasonableness would be overly permissive of objections at odds with professional healthcare standards. Finally, I argue for my favored solution, which bases the reasonability standard on minimal professional standards. (shrink)

The standard bioethics account is that respecting patient autonomy means ensuring that patients make their own decisions, and that requires that they give informed consent. In fact, respecting autonomy often has more to do with the overall shape and meaning of their health care regimes. Ideally, patients will sometimes take control of their health care but sometimes defer to medical authority. The physician's task is, in part, to inculcate patients into the appropriate good health care regimes.

An overview of the philosophical and bioethics literature on conscientious refusals by health care professionals to provide abortion and contraceptive services.

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

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

Patients in Quebec can legally obtain medical assistance in dying (MAID) if they are able to give informed consent, have a serious and incurable illness, are at the end of their lives and are in a situation of unbearable suffering. Since the Supreme Court of Canada’s 2015 Carter decision, access to MAID, under certain conditions, has become a constitutional right. Quebec physicians are now likely to receive requests for MAID from their patients. The Quebec and Canadian laws recognize a physician’s (...) right to conscientious objection, but this right is contested both in the medical ethics literature and in the public sphere. This paper presents the results of a qualitative study conducted with twenty Quebec physicians who did not integrate MAID into their medical practice, either because they were opposed to or deeply ambivalent about MAID. The interviews aimed to explore the reasons – religious and secular – for opposition to or ambivalence towards MAID. The secular reasons given by participants were grouped into four main categories: 1) the ends of medicine and professional identity, 2) the philosophy of palliative medicine and resource allocation in palliative care, 3) benevolent paternalism, the “good death”, and the interests of future selves, 4) the risk of a slippery slope and the protection of vulnerable people. (shrink)

Conscientious objection among physicians is a perennial hot topic on both sides of the Atlantic. Sven Nordstrand's survey of Norwegian medical students adds fresh data to this ongoing debate.1Their starting point, whether doctors should be allowed to refuse any procedure to which they object on cultural, moral or religious grounds, is truly at the heart of the debate. Their finding that only 20.8% of students endorse this position is striking as it is less than half the number reported by (...) Sophie Strickland in her survey of medical students in the UK.2 It also suggests much less support for conscientious objection than was found among USA primary care physicians, where 78% agreed that “A physician should never do what he or she believes is morally wrong, no matter what experts say.”3These data invite speculation about why there is such dramatic variation between countries. Much can be made of Nordstrand's comments that in Norway “each citizen is assigned a particular general practitioner” and “In the Norwegian healthcare system the general practitioner has a crucial role as …. (shrink)

In the debate on conscientious objection in healthcare, proponents of conscience rights often point to the imperative to protect the health professional’s moral integrity. Their opponents hold that the moral integrity argument alone can at most justify accommodation of conscientious objectors as a “moral courtesy”, as the argument is insufficient to establish a general moral right to accommodation, let alone a legal right. This text draws on political philosophy in order to argue for a legal right to accommodation. (...) The moral integrity arguments should be supplemented by the requirement to protect minority rights in liberal democracies. Citizens have a right to live in accordance with their fundamental moral convictions, and a right to equal access to employment. However, this right should not be unconditional, as that would unduly infringe on the rights of other citizens. The right must be limited to cases where the moral basis is more fundamental in a sense that all reasonable citizens in a liberal democracy should accept, such as the constitutive role of the inviolability of human life in liberal democracies. There should be a legal, yet circumscribed, right to accommodation for conscientious objectors refusing to provide healthcare services that they reasonably consider to involve the intentional killing of a human being. (shrink)

Freedom of Conscience and Freedom of Religion should be taken to protect two distinct sets of moral considerations. The former protects the ability of the agent to reflect critically upon the moral and political issues that arise in her society generally, and in her professional life more specifically. The latter protects the individual's ability to achieve secure membership in a set of practices and rituals that have as a moral function to inscribe her life in a temporally extended narrative. Once (...) these grounds are distinguished, it becomes more difficult to grant healthcare professionals' claims to religious exemptions on the basis of the latter than it is on the basis of the former. While both sets of considerations generate ‘internal reasons’ for rights to accommodation, the relevant ‘external’ reasons present in the case of claims of moral conscience do not possess analogues in the case of claims of religious conscience. However, the argument applies only to ‘irreducibly religious’ claims, that is to claims that cannot be translated into moral vocabulary. What's more, there may be reasons to grant the claims of religious persons to exemptions that have to do not with the nature of the claims, but with the beneficial effects that the presence of religious persons may have in the context of the healthcare institutions of multi-faith societies. (shrink)

Defenders of medical professionals’ rights to conscientious objection (CO) regarding emergency contraception (EC) draw an analogy to CO in the military. Such professionals object to EC since it has the possibility of harming zygotic life, yet if we accept this analogy and utilize jurisprudence to frame the associated public policy, those who refuse to dispense EC would not have their objection honored. Legal precedent holds that one must consistently object to all forms of the relevant activity. In the case (...) at hand, then, I argue that these professionals must also oppose morally innocuous practices that may prevent pregnancy after fertilization. These results reveal that such objectors cannot offer a plausible and consistent objection to harming zygotic life. Additionally, there are good reasons to reject the analogy itself. In either case, these findings call into question the case supporting refusals of EC based on scruples. (shrink)

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to (...) military service. We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. (shrink)

In a recent Bioethics editorial, Udo Schuklenk argues against allowing Canadian doctors to conscientiously object to any new euthanasia procedures approved by Parliament. In this he follows Julian Savulescu's 2006 BMJ paper which argued for the removal of the conscientious objection clause in the 1967 UK Abortion Act. Both authors advance powerful arguments based on the need for uniformity of service and on analogies with reprehensible kinds of personal exemption. In this article I want to defend the practice of (...) conscientious objection in publicly-funded healthcare systems, at least in the area of abortion and end-of-life care, without entering either of the substantive moral debates about the permissibility of either. My main claim is that Schuklenk and Savulescu have misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors. However, I acknowledge Schuklenk's point about differential access to lawful services in remote rural areas, and I argue that the health service should expend more to protect conscientious objection while ensuring universal access. (shrink)