Conscientious Objection Based on Patient Identity

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

The past decade has seen a burgeoning of scholarly interest in conscientious objection in health care. Specifically, several commentators have discussed the implications that conscientious objection has for the delivery of timely, efficient, and nondiscriminatory medical care. In this paper, I discuss the main argument put forward by the most prominent critics of conscientious objection-what I call the Professional Duty Argument or PDA. According to proponents of PDA, doctors should place patients' well-being and rights at the center of their professional practice. Doctors should be prepared to set their personal moral or religious beliefs aside where these beliefs conflict with what is legal and considered good medical practice by relevant professional associations. Conscientious objection, on this account, should be heavily restricted, if even allowed at all. I discuss two powerful objections against PDA. The first objection, which I call the fallibility objection, notes that law and professional codes of conduct are fallible guides for ethical conduct and that conscientious objection has in the past and continues today to provide a check on aberrations in law and professional convention. The second, which I call the professional discretion objection, states that restrictions on conscientious objection undermine one of the cornerstones of good medical practice, namely, a practitioner's right to independent professional judgment. I argue that these two objections give us reason to retain conscience clauses in professional codes of conduct.

Conscientious objection refers to refusal by a health care provider (HCP) to provide certain treatments, including the standard of care, to a patient based upon the provider's personal, ethical, or religious beliefs. Federal and state rules regarding conscientious objection have expanded the scope of legal protections that HCPs and institutions can invoke in support of refusal. Opponents of these rules argue that allowing refusal of care deprives patients of care that conforms to professionally established guidelines, contradicts long-standing principles related to informed consent, interferes with the ability of health care facilities to provide safe and efficient care, and leaves the patient without means of redress for injury. Proponents respond that such rules are necessary to preserve the moral integrity of providers, including institutions. Although refusal rules are most often associated with abortion, some HCPs have cited moral concerns regarding contraception, sterilization, prevention/treatment of sexually transmitted infections, transition-related care for transgender individuals, medication-assisted treatment of substance use disorders, the use of artificial reproductive technologies, and patient preferences for end-of-life care. Evidence suggests that the burden of conscientious refusal falls disproportionately on vulnerable populations, and legitimate concern exists that moral disagreement is merely pretext for discrimination. A careful balance must be struck between the defending the conscience rights of HCPs and the civil rights of patients.

Conscientious objection is a person's refusal to fulfill a legal duty due to their ethical values, religious beliefs, or ideological affiliations. In nursing, it refers to a nurse's refusal to perform an action or participate in a particular situation based on their conscience. Conscientious objection has become a highly contested topic in recent years. This study had four objectives: (1) eliciting information on how Turkish nurses perceive conscientious objection, (2) revealing whether their moral beliefs affect the care they provide, (3) determining their experiences with conscientious objection, and (4) identifying existing or potential issues of conscientious objection. This qualitative study collected data through semi-structured interviews. The data were analyzed using thematic content analysis. The sample consisted of 21 nurses. The study was approved by an ethics committee. Confidentiality and anonymity were guaranteed. Participation was voluntary. The analysis revealed four themes: (1) universal values of nursing (professional values), (2) experiences with conscientious objection (refusing to provide care/not providing care), (3) possible effects of conscientious objection (positive and negative), and (4) scope of conscientious objection (grounded and groundless). Participants did not want to provide care due to (1) patient characteristics or (2) their own religious and moral beliefs. Participants stated that conscientious objection should be limited in the case of moral dilemmas and accepted only if the healthcare team agreed on it. Further research is warranted to define conscientious objection and determine its possible effects, feasibility, and scope in Turkey.

In June, 2011, as it was becoming clear that the United States was moving towards a major confrontation on freedom of conscience in health care, the Brookings Institution in Washington, D.C. convened a symposium of theologians, philosophers, legal scholars, health practitioners and advocates representing different perspectives on the subject. The proceedings informed independent research by William A. Galston, a Senior Fellow at Brookings, and Melissa Rogers, director of Wake Forest University Divinity School’s Center for Religion and Public Affairs. Drawing from the symposium when appropriate, but citing or quoting participants only with their express permission, Galston and Rogers produced Care Providers’ Consciences and Patients’ Needs: The Quest for Balance, a report that reflects their own views on freedom of conscience in health care. It is hardly surprising that the authors focus on what others (not the authors) have called “the problem of conscientious objection.” However, even if the controversy begins with conscientious objection (and that is disputed) it does not follow that the problem is conscientious objection. One could as readily describe the problem as one of intolerance for moral or religious beliefs, or of social irresponsibility: that too many American health care workers are unwilling to do what they believe to be gravely wrong. The authors’ decision to discuss conscientious objection in health care rather than intolerance of moral beliefs suggests an orientation that is suspicious of the convictions of those who challenge the dominant professional and cultural ethos. Thus, the report has an orientation subtly but decidedly adverse to the exercise of freedom of conscience in health care. However, the cool, careful, measured and even-handed approach taken by the authors is admirable and particularly welcome. The authors are seeking common ground among those who believe that protecting freedom of conscience and securing access to health care are both important goals. They hope to encourage good will on all sides so that competing claims can be accomodated to the greatest extent possible. Health Care Providers’ Consciences and Patients’ Needs: The Quest for Balance makes a good start in that direction. It is a significant contribution to the current debate in the United States about freedom of conscience in healthcare, notwithstanding the reservations and criticism offered above. The authors have indicated that the report is subject to revision. One hopes that a future revision will incorporate the broader context and change of orientation suggested here.

We write to offer feedback on the new Faculty of Sexual & Reproductive Healthcare (FSRH) guideline1 on conscientious objection (CO) that was the subject of an editorial2 in the January...

Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

When healthcare professionals ask for a conscientious objection to be accommodated, they are requesting an exemption from a work role they object to, on moral or religious grounds. The word ‘conscience’ is sometimes taken to suggest a distinct mental faculty which generates moral responses. It would be a mistake to associate conscientious objections in healthcare too closely with the deliverances of conscience, however. Conscientious objections do not always involve the input of an objector’s conscience. But, they always involve moral or religious considerations. Conscientious objection was rarely discussed in healthcare contexts before the 1960s. Until then healthcare was permeated by a culture of medical paternalism, under which the values of doctors were effectively imposed on patients. Under the modern ethos of patient autonomy there is scope for patients to request, and to receive, forms of healthcare that healthcare professionals might find objectionable. So, they may want exemptions from some of the ordinary duties expected of them. If the healthcare institutions in which they work are to accommodate their wishes then either an arrangement needs to be made to ensure that other healthcare professionals undertake those duties, or some of the services that society licenses healthcare institutions to provide will not be provided. The 1973 Church Amendment exempted healthcare professionals in the United States from having to provide abortion or sterilisation services if doing so was inconsistent with their religious beliefs or moral convictions. Since then the scope of legal entitlement to conscientious accommodation has steadily expanded, in the United States and elsewhere. This expansion has begun to impact on healthcare provision, especially in respect of abortion. Unsurprisingly some commentators have started to think of ways to restrict conscientious accommodation. To what extent should conscientious objections be accommodated in healthcare? There is a plethora of answers to this question. Wicclair (2011) provides a helpful taxonomy of the different positions, recognising three different sorts. These are: (a) Conscience absolutism: the view that healthcare professionals should never be professionally obliged to act in any way they regard as violating of their consciences, (b) the incompatibility thesis, according to which no conscientious objection should be accommodated in the healthcare professions; and (c) compromise. Advocates of compromise hold that only some conscientious objections should be accommodated in the healthcare professions. In many public healthcare institutions, a healthcare professional who refuses to perform a medical procedure, on conscientious grounds, is expected to refer a patient requesting that procedure to another healthcare professional who is qualified, willing, and available to perform it. Referral is controversial because if a healthcare professional is convinced that a particular form of healthcare service is wrongful, then, were they to refer a patient, they would be complicit in an activity they regard as wrongful. The case for insisting on referral is that public healthcare systems have a duty to provide legal and safe forms of healthcare to patients.

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.

Conscientious objection in healthcare is often granted by many legislations regulating morally controversial medical procedures, such as abortion or medical assistance in dying. However, there is virtually no protection of positive claims of conscience, that is, of requests by healthcare professionals to provide certain services that they conscientiously believe ought to be provided, but that are ruled out by institutional policies. Positive claims of conscience have received comparatively little attention in academic debates. Some think that negative and positive claims of conscience deserve equal protection in terms of measures that institutions ought to take to accommodate them. However, in this issue of The Journal of Clinical Ethics (JCE), Abram Brummett argues against this symmetry thesis.1 He suggests that the relevant distinction is not between negative and positive claims of conscience, but between negative and positive rights of conscience. He argues that conscientious refusals and positive claims of conscience are both already protected as negative rights of conscience, but that this does not require institutions to accommodate positive claims of conscience. In this article I will argue that both Brummett and the authors he criticizes share a wrong view about the existence of conscience rights in healthcare. I will argue that there is no right to conscientious objection in healthcare, whether positive or negative. Thus, contra Brummett, I argue that the question whether such rights are positive or negative is as irrelevant as the question whether the claims of conscience are positive or negative.

44. Conscientious Objection By Primary Care Trainee And Faculty Physicians In An Appalachian Health Care System

To examine nursing experiences and perspectives regarding conscientious objection in healthcare practice. Qualitative Systematic Review. The studies were identified, screened and appraised using the Joanna Briggs Institute (JBI) model and appraisal tools to assess the quality of the data and ensure rigorous evaluation. Five databases, including PubMed, CINAHL, Emcare, Scopus and PsycINFO, were searched from September 2024 to December 2024 to identify existing qualitative studies on nurses' experiences and perspectives on conscientious objection. 15 studies from 1998 to 2024 were included in this review from 11 different countries. The synthesised findings identified five themes related to nurses' experiences and perspectives of conscientious objection: (1) Conflict with Moral, Ethics, Religious and Personal Beliefs and Values; (2) Conflicts with Policy and Law; (3) Work Expectations, Team Decisions and Dynamics; (4) Conflict over Care Dilemmas; (5) Forms of Conscientious Objection. Nurses from various clinical settings reported various perspectives on conscientious objection, identifying different clinical care experiences, personal ethical and religious conflicts, and ways in which they managed forms of conscientious objection in practice. The various conflicts may impact nurses by promoting burnout, stress and emotional exhaustion. Understanding nurses' perspectives on conscientious objection allows clinical managers, stakeholders and policymakers to give nurses an opportunity to object conscientiously based on ethical and religious beliefs and create clear guidelines for ethical decision-making. Such guidelines allow nurses to conscientiously object while still maintaining professional standards and minimising adverse effects on the care provided to patients. Allowing conscientious objection has important implications for nursing practice, particularly in balancing professional responsibilities with personal and religious convictions. This qualitative systematic review was reported in accordance with the PRISMA 2020 guidelines. PROSPERO number: CRD42024599651.

Daniel Sulmasy has recently argued that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences. The only constraints Sulmasy believes we should place on physicians' discretionary space are those defined by a form of tolerance he derives from Locke, whereby people can publicly act in accordance with their personal religious and moral beliefs as long as their actions are not destructive to society. Sulmasy also claims that those who would reject physicians' right to conscientious objection eliminate discretionary space, thus undermining good medicine and unnecessarily limiting religious freedom. I argue that, although Sulmasy is correct that some discretionary space is necessary for good medicine, he is wrong in thinking that proscribing conscientious objection entails eliminating discretionary space. I illustrate this using Julian Savulescu and Udo Schuklenk's system for restricting conscientious objections as a counter-example. I then argue that a narrow discretionary space constrained by professional ideals will promote good medicine better than Sulmasy's wider discretionary space constrained by his conception of tolerance. Sulmasy's version of discretionary space would have us tolerate actions that are at odds with aspects of good medicine, including aspects that Sulmasy himself explicitly values, such as fiduciary duty. Therefore, if we want the degree of religious freedom in the public sphere that Sulmasy favours then we must decide whether it is worth the cost to the healthcare system.

Michael Robinson takes issue with an ‘argument from voluntariness’ made by several opponents of current practices for managing conscientious objection (CO) in healthcare, including Cantor, Stahl and Emanuel, and Schuklenk,...

A dogma accepted in many ethical, religious, and legal frameworks is that the reasons behind conscientious objection (CO) in healthcare cannot be evaluated or judged by any institution because conscience is individual and autonomous. This paper shows that this background view is mistaken: the requirement to reveal and explain the reasons for conscientious objection in healthcare is ethically justified and legally desirable. Referring to real healthcare cases and legal regulations, this paper argues that these reasons should be evaluated either ex ante or ex post and defends novel conceptual claims that have not been analyzed in the debates on CO. First, a moral threshold requirement: CO is only justified if the reasons behind a refusal are of a moral nature and meet a certain threshold of moral importance. Second, this paper considers the rarely discussed conceptual similarities between CO in healthcare and the legal regulations concerning military refusals that place the burden of proof on conscientious objectors. This paper concludes that conscientious objection in healthcare can be accommodated only in some cases of destroying or killing human organisms.