Virtue in Medicine: The Foundation Protecting Conscientious Objection from Moral Relativism

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

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.

Conscientious Objection Based on Patient Identity

A dogma accepted in many ethical and legal frameworks is that the reasons that lie behind conscientious objection (CO) in healthcare cannot be evaluated or judged by anyone other than the objector herself, because conscience is individual, autonomous, and inaccessible to any outside evaluation. In this paper I argue that this view is mistaken: physicians have an obligation to reveal and explain their reasons for CO and that these reasons may be evaluated either ex ante or ex post. In arguing for my claims I refer mostly to the Polish context and I defend some novel claims that have not been analyzed extensively in the debates on CO. First, I introduce a moral threshold requirement: CO is justified only if the reasons behind a refusal are of moral nature and meet a certain threshold of importance. Second, I highlight the similarities between CO in healthcare and the regulations concerning military refusals, including an emerging practice of granting the right to selective CO status to professional soldiers, that places the burden of proof on a petitioner for CO status. My argument highlights the special status of refusing to kill human organism (military conflicts, abortion, assisted-suicide), and shows that certain other common forms of CO do not warrant accommodation (e.g. emergency contraception).

Article 9 of the European Convention on Human Rights provides protection for freedom of thought, conscience and religion. From one perspective, it may be said that Article 9 guarantees a right to conscientious objection in health care, whereas from another perspective, a Strasbourg case, such as Pichon and Sajous v France, effectively means that Article 9 provides little or no protection in that context. In this article it is argued that the matter is more complex than either of these two positions would suggest. Moreover, given the nature of the subject matter, national authorities should be afforded a significant margin of appreciation in the way that they protect and regulate conscientious objection. By way of illustration, there is a discussion of the ways in which Article 9 might affect conscientious objection in health care under English law. The final part of the article considers the conceptual limitations of Article 9 in thinking about conscientious objection in health care; in particular, the claim that the extent to which Article 9 of the Convention provides protection for a conscientious objection in the health care context is a different question from whether conscientious objection by doctors and other health care practitioners is justified in principle.

Background: Conscientious objection (CO) in healthcare has always been a controversial topic. Some healthcare professionals perceive CO as a freedom of conscience, others believe their duty-of-care overrides personal perspectives. There is a paucity of literature pertaining to pharmacists’ perspectives on CO. This study aimed to inform the development of a proposed questionnaire exploring pharmacists’ decision-making in complex scenarios around CO and reasons for their choices. Methods: This was a cross-sectional, mixed methods pilot study of international pharmacists, using an online, vignette-based questionnaire on scenarios related to medical termination, emergency contraception, IVF surrogacy for a same-sex couple and voluntary assisted dying (VAD). Results: Sixty-two FIP 2019 conference delegate pharmacists participated in this pilot study. Approximately half them believed pharmacists have the right to CO. Most pharmacists agreed to supply the prescriptions across all four vignettes. Regarding continuity of care, majority of pharmacists agreed (97%) it was necessary for equity of access. Strong self-reported religiosity had a statistically significant relationship with pharmacists’ decisions not to supply for medical termination, IVF surrogacy and VAD. Conclusion: This pilot study revealed insights into the various perspectives of international pharmacists on CO in healthcare and informed the development of a survey for future administration.

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...

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.

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.

Prominent consequentialists who write about conscientious objection (CO) in healthcare, Julian Savulescu and Udo Schüklenk, both argue for the 'incompatibility thesis'-the view that healthcare professionals ought never to be entitled to exercise a CO to absolve themselves of the responsibility to perform professional duties. I argue, contra Savulescu and Schüklenk, that consequentialists should advocate for a compromise position under which healthcare professionals are entitled to conscientiously object to providing some services under some circumstances. The compromise advocated differs dramatically from the most prominent compromise position in the academic literature on CO in healthcare, Brock's 'conventional compromise'. The conventional compromise relies on referral, and I show that this is a problematic tool for consequentialists to rely on. I argue that the best approach to managing CO, from a consequentialist point of view, is to set up a system of region-based registers of available healthcare professionals who lack COs to procedures for which COs are permitted. Patients and healthcare professionals in the given region would be able to access-and be encouraged to consult-the register for their region before receiving any form of healthcare for which COs are permitted, thereby eliminating the need for referral in most circumstances.

Much ink has been spilled in recent years over the controversial topic of conscientious objection in health care. In particular, commentators have proposed various ways with which we might distinguish legitimate conscience claims from those that are poorly reasoned or based on prejudice. The aim of this chapter is to argue in favor of the “reasonableness” approach to conscientious objection, viz., the view that we should develop an account of “reasonableness” and “reasonable disagreement” and use this as a way of distinguishing licit and illicit conscience claims. The author discusses Rawls’ account of “reasonableness” and “reasonable disagreement,” and consider how this might guide us in regulating conscientious objection in health care. The author analyzes the “public reason” account offered in Card (2007, 2014), and argue that we should modify Card’s account to include a consensus among regulators about what counts as “basic medical care.” The author suggests that Medical Conscientious Objection Review boards should consider whether conscience-based refusals are based on defensible ethical foundations.

611 Abstract. Conscientious objection in the health care field—that is, refusal on the part of a medical professional to perform or cooperate in a procedure when it violates his or her conscience—is a growing concern for international legislators and a source of contentious debates among ethicists and the general public. Recognizing a general right to conscientious objection based on individual liberty, and thus a subjective right, could have negative consequences. Conscientious objection in health care settings should be fully protected, however, when the objection is based on principles that are fundamental to the medical profession and the legal system. Examples from Italy and other nations show how protections there safeguard conscientious objection when a health professional objects to taking a human life. National Catholic Bioethics Quarterly 12.4 (Winter 2012): 611–620.

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.

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.