Ever since medical assistance in dying (MAID) became legal in Canada in 2016, controversy has enveloped the refusal by many faith‐based institutions to allow this service on their premises. In a recent article in this journal, Philip and Joshua Shadd have proposed ‘changing the conversation’ on this issue, reframing it as an exercise not of conscience but of an institutional right of self‐governance. This reframing, they claim, will serve to show how health‐care institutions may be justified in refusing to provide (...) MAID on moral or religious grounds. I argue that it will not make it easier to justify institutional refusal, and is likely to make it harder. (shrink)

Whether institutions and not just individual doctors have a right to not participate in medical assistance in dying (MAID) is controversial, but there is a tendency to frame the issue of institutional non‐participation in a particular way. Conscience is central to this framing. Non‐participating health centres are assumed to be religious and full participation is expected unless a centre objects on conscience grounds. In this paper we seek to reframe the issue. Institutional non‐participation is plausibly not primarily, let alone exclusively, (...) about conscience. We seek to reframe the issue by making two main points. First, institutional non‐participation is primarily a matter of institutional self‐governance. We suggest that institutions have a natural right of self‐governance which, in the case of health centres such as hospitals or hospices, includes the right to choose whether or not to offer MAID. Second, there are various legitimate reasons unrelated to conscience for which a health centre might not offer MAID. These range from considerations such as institutional capacity and expertise to a potential contradiction with palliative care and a concern to not conflate palliative care and MAID in public consciousness. It is a mistake to frame the conversation simply in terms of conscience‐based opposition to MAID or full participation. Our goal is to open up new space in the conversation, for reasons unrelated to conscience as well as for non‐religious health centres who might nonetheless have legitimate grounds for not participating in MAID. (shrink)

In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors' personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue (...) that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: removing a right to conscientious objection; selecting candidates into relevant medical specialities or general practice who do not have objections; demonopolizing the provision of these services away from the medical profession. (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. 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)

This paper argues that the professional situation of junior doctors is unique in ethically important ways and thus that ethics work focusing on junior doctors specifically is necessary. Unlike the medical student or the more senior doctor, the doctor in his or her early postgraduate years is simultaneously a responsible health professional, a subjugate learner and a human resource. These multiple roles generate the set of ethical issues faced by junior doctors, a set that has some overlaps with that faced (...) by medical students and with that faced by more experienced doctors but is far from completely continuous with either. Further, the multiple roles that junior doctors play affect their options for negotiating the ethical challenges that they face. Their position determines not only the content of the set of ethical issues that they encounter, but also the kinds of actions they can take in the face of these challenges. Thus considering junior doctors only in combination with medical students or more senior doctors fails on two fronts. Firstly, only a very incomplete set of the ethical issues faced by junior doctors will be addressed, and, secondly, the constraints associated with the specific professional situation of junior doctors will not be adequately considered, limiting the practical applicability for these agents of any such analyses. (shrink)

In this paper I argue that junior doctors are morally exploited. Moral exploitation occurs where an individual’s vulnerability is used to compel them to take on additional moral burdens. These might include additional moral responsibility, making weighty moral decisions and shouldering the consequent emotions. Key to the concept of exploitation is vulnerability and here I build on Rosalind McDougall’s work on the key roles of junior doctors to show how these leave them open to moral exploitation by restricting their reasonable (...) options. I argue that there are a number of ways junior doctors are morally exploited. First, their seniors can leverage their position to force a junior to take on some discreet decision. More common is the second type of moral exploitation where rota gaps and staffing issues means junior doctors take on more than their fair share of the moral burdens of practice. Third, I discuss structural moral exploitation where the system offloads moral burdens onto healthcare professionals. Not every instance of exploitation is wrongful and so I conclude by exploring the ways that moral exploitation wrongs junior doctors. (shrink)

In his paper ‘The truth behind conscientious objection’ Nir Ben-Moshe develops a new approach aimed at justifying conscientious objection without relying on respect of moral integrity of the conscientious objector or tolerance towards her moral views.1 According to Ben-Moshe, the problem with justifications of CO based on moral integrity and tolerance is that ‘truth of conscience’s claims is irrelevant to their justification’. He argues, to the contrary, that whether the claims of the conscientious objector are true or false makes a (...) difference in assessing whether their objection is justifiable or not. He goes on explaining that someone’s CO can be justified if it can be proved that ‘conscience can express true moral claims’. Ben-Moshe then proceeds to explain how one can determine true moral claims. He develops an account of conscience that is modelled on that of Adam Smith. In particular, he uses the idea of the ‘impartial spectator’ to show how a true claim of conscience can emerge after careful thinking from the point of view of an impartial perspective. So, if the healthcare practitioner wants to object to a certain medical procedure after considering the issue at hand from the moral standpoint of such impartial spectator, then her claims of conscience are true (or …. (shrink)

BackgroundIn June 2019, the Australian state of Victoria joined the growing number of jurisdictions around the world to have legalised some form of voluntary assisted dying. A discourse of safety was prominent during the implementation of the Victorian legislation.Main textIn this paper, we analyse the ethical relationship between legislative “safeguards” and equal access. Drawing primarily on Ruger’s model of equal access to health care services, we analyse the Victorian approach to voluntary assisted dying in terms of four dimensions: horizontal equity, (...) patient agency, high quality care, and supportive social norms. We argue that some provisions framed as safeguards in the legislation create significant barriers to equal access for eligible patients.ConclusionsWhile safety is undoubtedly ethically important, we caution against an overemphasis on safeguarding in voluntary assisted dying legislation given the implications for equal access. (shrink)

There is increasing recognition among bioethicists that health-care practitioners' everyday ethical challenges ought to be the focus of ethical analysis. Interviews were conducted with Australian junior doctors to identify some of the kinds of situations that they found ethically challenging, as a basis for this type of grounded philosophical analysis and for further empirical research into junior doctors' ethical issues. Fourteen doctors in their first to fourth year of work from six hospitals in Melbourne participated. Issues discussed included involvement in (...) treatment perceived as inappropriate, seniors discouraging disclosure of errors, coping when requested help was not forthcoming, observing behaviour perceived as unethical, truth-telling and informed consent. The difficulties described often focused on interactions with colleagues and position in the health-care team. Although the results cannot be generalized to junior doctors as a population, these junior doctors' stories point to various issues warranting further investigation, both philosophical and empirical. (shrink)

In this study, we sought to obtain detailed opinion on some of the practical issues that might arise should physician-assisted suicide (PAS) ever be legalized in the UK. We carried out an anonymous postal questionnaire of medical students, junior and senior doctors working at an acute hospital trust, over a three-week period. A total of 435 questionnaires were distributed and we had an overall return rate of 34%. We found that opinions changed very little as doctors progressed from medical school (...) through to senior clinical positions. Overall, there was neutral opinion on whether PAS should be legalized. There was strong support for a multidisciplinary approach to the process and the involvement of the coroner. An opt-out clause for physicians who did not want to be involved in assisted suicide also received strong support. (shrink)

In his recent article, Ben-Moshe offers an account of conscientious objection in terms of the truth of the underlying moral objections, as judged by the standards of an impartial spectator. He seems to advocate for the view that having a valid moral objection to X is the sole criteria for the instantiation of a right to conscientiously object to X, and seems indifferent to the moral status of the prevailing moral attitudes. I argue that the moral status of the prevailing (...) moral attitudes is relevant, and that a good faith disagreement between those who condone the relevant act and those who object to it is a criterion for CO. In this light, I suggest that CO is a sociopolitical device for managing differing ethical perspectives, particularly in the context of collective moral change. Thus, it is misguided to equate having a valid moral objection with the recognition of a CO. (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)

Answers to the questions of what justifies conscientious objection in medicine in general and which specific objections should be respected have proven to be elusive. In this paper, I develop a new framework for conscientious objection in medicine that is based on the idea that conscience can express true moral claims. I draw on one of the historical roots, found in Adam Smith’s impartial spectator account, of the idea that an agent’s conscience can determine the correct moral norms, even if (...) the agent’s society has endorsed different norms. In particular, I argue that when a medical professional is reasoning from the standpoint of an impartial spectator, his or her claims of conscience are true, or at least approximate moral truth to the greatest degree possible for creatures like us, and should thus be respected. In addition to providing a justification for conscientious objection in medicine by appealing to the potential truth of the objection, the account advances the debate regarding the integrity and toleration justifications for conscientious objection, since the standard of the impartial spectator specifies the boundaries of legitimate appeals to moral integrity and toleration. The impartial spectator also provides a standpoint of shared deliberation and public reasons, from which a conscientious objector can make their case in terms that other people who adopt this standpoint can and should accept, thus offering a standard fitting to liberal democracies. (shrink)