Conscience In Health Care Research Articles

Stress of conscience in healthcare in turbulent times: A longitudinal study.

Healthcare workers frequently face ethically demanding situations in their work, potentially leading to stress of conscience. Long-term work intensification (more and more effort demanded year after year), organizational change and COVID-19 may be risk factors concerning stress of conscience. The main aim was to investigate the relationship between long-term work intensification and stress of conscience among the personnel in a healthcare organization. Organizational change management was considered a mediator and COVID-19-related work stress a moderator in the association between work intensification and stress of conscience. A total of 211 healthcare district employees participated in a longitudinal survey using questionnaires collected in 2019 (major organizational change in the planning stage) and 2021 (organizational change completed). The study was implemented according to the guidelines of the Finnish National Board on Research Integrity. The Finnish instructions were that no review by an ethics committee was necessary because participation was voluntary, informed consent was requested, participants were assured that they were free to withdraw from the longitudinal study at any time and no health data were collected. Long-term work intensification was associated with more severe stress of conscience. Long-term work intensification was partially mediated through change management to stress of conscience. High COVID-19 stress strengthened the association between long-term work intensification and stress of conscience. Long-term work intensification must be addressed to reduce stress of conscience in healthcare, otherwise the healthcare system will be vulnerable to changes and crisis. Extra resources for personnel and management should be allocated because of work intensification during organizational change and health crises like the COVID-19 pandemic to alleviate stress of conscience.

Considerations of Conscience.

The proper role of conscience in healthcare continues to be a topic of deep interest for bioethicists, healthcare professionals, and health policy experts. This issue of HEC Forum brings together a collection of articles about features of these ongoing discussions of conscience, advancing the conversations about conscience in healthcare from a variety of perspectives and on a variety of fronts. Some articles in this issue take up particularly challenging cases of conscientious objection in practice, such as Fleming, Frith, and Ramsayer's contextually rich piece on midwives in Scotland or Harter's professionally grounded analysis; others engage the changing institutional landscapes which impact considerations of conscience, such as Cummins' work on the role of employers in institutional policies about conscience and Ben Moshe's discussion of publicity and institutional committees. Pieces by Howard and Pilkington both raise conceptual considerations about how we think about the role of conscience in medicine, questioning the use of "conscientious objection" in these discussions, and Byrnes pushes back on the most influential work in this area by Mark Wicclair. The issue concludes with a piece by Wicclair, which engages each of these distinct offerings, further extending the discussions of conscience in healthcare and helpfully connecting key themes discussed by authors in this issue to his contributions and to the longer tradition of discussions of conscience in medicine. This issue challenges readers to engage different arguments from different perspectives and asks them-in some cases-to be open to revising how they think about the role of conscience and the existence of and justification for conscientious objection in the dynamic, interdisciplinary fields of healthcare.

Submission to the World Medical Association Re: International Code of Medical Ethics revision

This submission responds to the World Medical Association (WMA) request for public feedback about a proposed revision to the International Code of Medical Ethics (ICME). Amendments to Paragraphs 14 (Patient-centred practice) and 27 (“Conscientious objection”) are the principal concern. Paragraph 14 (Patient-centred practice) expresses the central principle of the ICME. Current controversies about freedom of conscience in health care frequently manifest fundamental disagreement about the meaning of terms used here: “care”, “health”, “well-being” and “best interest.” The Project recommends that “care” be replaced with “recommendations and treatment.” What is thought to be in a patient’s “best interest” can be disputed for a variety of legitimate reasons. The ICME should indicate the role and obligations of physicians by specifying that recommendations and treatments must be only those a physician “believes in good faith” to be in a patient’s best interest, “belief” making clear that the judgement is that of the physician, and “good faith” indicating reasonableness, good will and absence of duplicity, prejudice or discrimination. The proposed text of Paragraph 27 (“Conscientious objection”) is anomalous in relation to medical practice because it ignores the role of conscience in medicine and adopts an inadequate and prejudicial analytical framework. It does not attempt or even suggest how to accommodate physician integrity and patient requests when they conflict. It is also anomalous in relation to existing WMA policy and related functionally interdependent paragraphs in the proposed ICME. The Project proposes an amended Paragraph 27 that ∙ reflects the role of conscience in medical practice; ∙ identifies conduct morally relevant to participation in contested procedures; ∙ recognizing the potential for conflict between physicians and state or other authorities, brings other provisions of the ICME into play; ∙ includes brief guidance about physician obligations to provide information and ensure patient safety and continuity of care. The Project recommends that the ICME be supplemented by WMA policy on physician freedom of conscience. It strongly urges that a planned WMA conference should focus on conscience in medical practice, not conscientious objection.

Freedom of Conscience in Health Care: ‘An Interesting Moral Swamp’?

Public and professional discourse is often dominated by polarized factions primarily interested in expanding or restricting access to X. Few seriously attend to the meaning and significance of freedom, conscience, health, care — and freedom of conscience — except to the extent that such concepts can be made to serve a “pro” or “anti” agenda or to conform to notions of autonomy and contract.

A defense of conscience in healthcare

Summary Robert P. George is McCormick Professor of Jurisprudence and Director of the James Madison Program in American Ideals and Institutions at Princeton University. In “A Defense of Conscience in Healthcare ”, Dr. George reacts to Ethics Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG). Among other things, the opinion proposes that physicians in the field of women's health be required as a matter of ethical duty to refer patients for abortions and sometimes even to perform abortions themselves. Dr. George first responds to this imperative by challenging the nature of elective abortion itself as normal healthcare, based on the implicit judgment that pregnancy, when unwanted, is in effect a disease. In fact, the issues in dispute are philosophical; they cannot be resolved by science or methods of scientific inquiry. If this is the case, there is therefore no justification to compel morally sincere physicians who disagree with this judgment to violate their conscience or else leave the practice of medicine entirely. The ACOG statement fails to acknowledge the widespread debate about abortion in our society and the moral sincerity of pro-life practitioners.

Professionalism, autonomy, and the right of conscience: A call for balance

Summary The theme of this issue of Ethics, Medicine, and Public Health is “Healthcare Rights of Conscience.” The guest editor is Dr. Dennis Sullivan, a retired physician and university professor, and former director of the Center for Bioethics at Cedarville University. Dr. Sullivan's paper is entitled: “Professionalism, Autonomy , and the Right of Conscience: A Call for Balance.” He begins by contrasting modern oaths taken by today's aspiring physicians to the ancient Oath of Hippocrates from 400 BCE. He notes that the main difference is the modern notion of autonomy, missing from the original Oath but so important to the ethics of modern medical practice. He suggests, however, that while allowing patients to make their own decisions is clearly a key value, some of the key tenets of medical professionalism may get lost in the process. As a corrective, Sullivan recommends a renewed emphasis on virtue ethics, which originated with another ancient Greek source, Aristotle . With this background, Sullivan introduces the theme of this issue that of healthcare conscience rights. The Trump Administration has opened a new Conscience and Religious Freedom Division (under Health and Human Services), with new rules to allow clinicians with religious or moral objections to opt out of providing certain medical services. Navigating all of this may be difficult, however, for such accommodations are not unlimited. Conscience rights should be respected and protected by law, but patients have a right to legal treatments, and may not be abandoned by the healthcare system. Are some patients denied care as a result of conscience claims, or are they simply inconvenienced? After previewing the six papers on rights of conscience, Sullivan concludes with an appeal to professionalism that embodies the spirit of Hippocrates, but with a renewed sense of compassion and dedication to the well-being of every patient.

Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise

Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise

Conscientious Refusal, the Requirement of Justification, and the Fetishisation of Conscience in Healthcare: A Polish Perspective

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).

Unpacking the Relationship between Conscience and Access

Many people reflexively accept or reject healthcare conscience protections. Those prizing religious freedom argue that conscience protections ensure that religious believers can both take jobs in medicine and act consonant with their faith. This group sometimes gives short shrift to concerns about access to needed medical services. On the other side, advocates for reproductive rights sometimes see access concerns as so overriding that no religious convictions should ever be accommodated, even when there would not be impact on access. Both accounts are too simplistic. This chapter provides a more nuanced account of healthcare conscience protections that balances the concerns of access and conscience. It does so by dividing conscious clauses into categories that are access-expanding, access-neutral, or access-contracting, distilling characteristics that make a conscience clause a threat to access, a wash for access, or, counter-intuitively, access-enhancing. This chapter also recognizes the challenge of access-freezing “super conscience clauses.” This chapter demonstrates that it is possible to balance conscience and access in at least some cases by using common-sense devices, such as notice, parity rules, protections conditioned on not causing harm, and thickened duties to transfer pregnant women in distress. This Chapter recognizes that some protections jeopardize access more than others. In a civil society, we should strive to maximize conscience protections without jeopardizing access. As the U.S. Supreme Court’s remand in Zubik v. Burwell reminds us, realizing reproductive access without encroaching on conscience is sometimes achievable and a desirable goal.

Whose Choice? Developing a Unifying Ethical Framework for Conscience Laws in Health Care.

Since abortion became legal nationwide, federal and state "conscience clauses" have been established to define the context in which health professionals may decline to participate in contested services. Patients and health care providers may act according to conscience in making health care decisions and in deciding whether to abstain from or to participate in contested services. Historically, however, conscience clauses largely have equated conscience in health care with provider abstinence from such services. We propose a framework to analyze the ethical implications of conscience laws. There is a rich literature on the exercise of conscience in the clinical encounter. This essay addresses the need to ensure that policy, too, is grounded in an ethical framework. We argue that the ideal law meets three standards: it protects patients' exercise of conscience, it safeguards health care providers' rights of conscience, and it does not contradict standards of ethical conduct established by professional societies. We have chosen Illinois as a test of our framework because it has one of the nation's broadest conscience clauses and because an amendment to ensure that women receive consistent access to contested services has just passed in the state legislature. Without such an amendment, Illinois law fails all three standards of our framework. If signed by the governor, the amended law will provide protections for patients' positive claims of conscience. We recommend further protections for providers' positive claims as well. Enacting such changes would offer a model for how ethics-based analysis could be applied to similar policies nationwide.

The Problem of Unregulated Conscientious Objection

In late 2010, Parliamentary Assembly of Council of Europe (PACE) was presented with a report from its Social, Health and Family Affairs Committee expressing deep concern about problem of conscientious objection in Europe. The Committee proposed to solve this problem by having states adopt comprehensive and clear regulations to address it. Since that time, several authors and organizations have repeatedly drawn attention to same problem. One of consistent themes in these complaints is that conscientious objection is illegitimate and/or unethical because it hinders access to lawful drugs, procedures or services. Time magazine has provided a current example of this problem. By September, article states, Texas will run out of sole drug it uses in lethal injections thanks in part to an overseas effort that has persuaded a European pharmaceutical company [Lundbeck] to halt its supply to U.S. states for use in executions. Time did not make connection between Lundbeck’s refusal to supply pentobarbital to executioners and ongoing controversy about freedom of conscience in health care. The story of Lundbeck and Pharmaceutical Hippocratic Oath is not just a story about opposition to capital punishment, but about the problem of unregulated conscientious objection, presented in a new and potentially enlightening context.

Freedom of Conscience in Health Care: Distinctions and Limits

The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the dictates of regulatory bodies and administrators. Increasing attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom.

Conscience in health care and the definitions of death

Brain death or neurologic death has gradually become recognized as human death over the past decades worldwide. Nevertheless, in Japan, the New York State, and the State of New Jersey, one can be exempt from death determination based on neurologic criteria even in the state of brain death. In Japan, the 1997 Act on Organ Transplantation legalized brain death determination exclusively when organs were to be procured from brain-dead patients. Even after the 2009 revision, the default definition of death continued to be cardio-pulmonary criteria, despite the criticism. The cases of Japan and the United States provide a good reference as social experiments of appreciating conscientious or religio-cultural dimensions in health care. This text theoretically examines the 1997 Act on Organ Transplantation of Japan and its 2009 revision, presenting some characteristics of Japan’s case compared to American cases and the implications its approach has for the rest of the world. This is an example in which a foreign idea that did not receive widespread support from Japanese citizens was transformed to fit the religio-cultural landscape.

Professional Autonomy in Medicine: Defending the Right of Conscience in Health Care beyond the Right to Religious Freedom.

Health-care professionals currently have the right to conscientiously object to any procedure that they deem as morally illicit or that, in their opinion, could harm the patient. However, the right of conscientious refusal in medicine is currently under severe scrutiny. Medical procedures such as abortion and physician-assisted suicide that are not commonly medically indicated, but that can be requested by the patient, represent a type of medical care that is the penultimate expression of patient autonomy. When a health-care provider exercises his or her conscience in a way that denies the patient immediate access to such procedures, many claim that patient autonomy has been oppressed by the religious convictions of the health-care professional. As such, there is a growing opposition to the protection of conscience rights in health care that deserves attention. A common strategy used to defend conscience rights has been to claim that under the United States Bill of Rights, the health-care professional must be allowed to exercise their religious liberties in the context of their profession. This rationale seems to ignite a more intense opposition to conscience rights as it seems to validate the sense that a health-care professional's religious convictions are protected at the cost of patient autonomy. This paper reviews the current status of this debate and proposes a defense of conscience rights in health care that considers both the autonomy of the health-care worker and that of the patient in the context of the patient-physician relationship.

The Importance of Orientation: Review of 'Health Care Providers’ Consciences and Patients’ Needs: The Quest for Balance'

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.

Notes Toward an Understanding of Freedom of Conscience

Commentators wrestling with conflicts between claims of conscience made by health care workers and demands for morally controversial services have offered a variety of responses. Despite these efforts, controversy about freedom of conscience in health care continues. It subsides from time to time, only to erupt again with renewed force when tectonic political and social forces collide. Discussion has not gone deep enough to address underlying disagreements about the nature of the human person that shape disputes about freedom of conscience. Proposals to limit freedom of conscience must first take into account the distinction between its perfective and preservative forms. Limiting perfective freedom of conscience prevents people from doing the good that they wish to do, and may (if no alternatives are available) prevent them from perfecting themselves, fulfilling their personal aspirations or achieving some social goals. This may do them some wrong. But if it does them some wrong, it does not necessarily do them an injury. In contrast, to force people to do something they believe to be wrong is always an assault on their personal dignity and essential humanity, even if they are objectively in error; it is always harmful to the individual, and it always has negative implications for society. This does not mean that no limit can ever be placed on preservative freedom of conscience. It does mean, however, that even the strict approach taken to limiting other fundamental rights and freedoms is not sufficiently refined to be safely applied to limit freedom of conscience in its preservative form. The stakes are far too high. Like the use of potentially deadly force, if the restriction of preservative freedom of conscience can be justified at all, it will only be as a last resort, and only in the most exceptional circumstances.

An Institutional Solution to Conflicts of Conscience in Medicine

Conflicts of Conscience in Health Care: An Institutional Compromise. By Holly Fernandez Lynch. The MIT Press, 2008. 358 pages. Hardcover. $34.00. One of the most intriguing questions in medical ethics is whether individual physicians ought to be able to refuse conscientiously to provide services that patients seek. The issue requires us to delve into difficult problems, such as the extent to which physicians must subordinate their interests to those of their current or prospective patients, and how essential the services physicians object to are as new medical technologies develop. Despite the difficulty that surrounds this issue, many bioethicists--like Dan Brock and Mark Wicclair--have tried to address it in a single journal article. But Holly Fernandez Lynch is an exception. She gives objection in medicine (hereafter, conscientious objection) the book-length treatment that it deserves. Lynch opposes a blanket prohibition on objection. Among her reasons are that patients are not well served by physicians who have serious moral qualms about services that the patients need, and that medical professionalism does not require physicians to take all comers or to accede to all requests--even legitimate ones. She further explains that some refusals--such as a refusal to assist a sixty-year-old woman in conceiving a child--may be appropriate. We should not prevent physicians from making good objections, and we can probably think of some regardless of what our moral commitments are. Lynch concludes that we need to allow some objection; however, some readers will find that she exaggerates this need. For example, some will object to what she says is the strongest argument for retaining room for moral refusers: the inability to know the answers to many of the moral questions that create controversy in medicine, such as whether a fetus is a person. Some readers will have more faith than Lynch does in the resources of moral philosophy to provide proofs for such claims. Some may also feel that she overstates the importance of allowing objection by defining the term too broadly. For her, objection includes refusals grounded in values that are widely held within the profession and have been accepted as clinical standards (p. 34). An example would be a refusal to allow a sick child to decide on his own what his treatment will be. This unusually broad conception allows Lynch to say that taking a strong stand against objection commits one to the unhappy view that physicians are mere technicians who have no personal autonomy or morality of their own. If the professional standard is no objection, then physicians can never object to patient requests on grounds of conscience, even when their conscience aligns with what their profession requires of them. But is such absurdity a consequence of refusing to condone objection? Not if the category refers, as Dan Brock believes it does, only to objections to what is legal and professionally accepted. Even those of us who feel she exaggerates, however, could agree with Lynch that a strict prohibition on objection is inappropriate. The question then becomes: How are we to make room for objection without eliminating patients' access to important medical care? Lynch develops an institutional solution to this problem, the details of which take up much of her book. The book has three main parts. In part one, Lynch describes the legal situation and the debate about objection in the United States. She argues in favor of resolving the debate by determining whether physicians have professional obligations that preclude them from exercising freedom of conscience in their capacity as physicians. She favors a model of medical professionalism that she calls the gate-keeping paradigm. …

Individual Rights vs. Institutional Identity: The Relational Dimension of Conscience in Health Care

In the debates over the role of a provider’s conscience in the provision of health care, both sides engage the question in individualist terms, as though the only relevant choice is whether to enshrine a liberty right for the customer or a liberty right for the provider. Little attention is paid to the value of institutional identity. The conscience-driven practices of providers are not inherently less legitimate than the conscience-driven needs and preferences of health care customers, provided that goods and services to meet customers’ needs and preferences are accessible. In a functioning market, the viability of conscience requires us to give providers – and like-minded customers – an opportunity to live out their ideals. By more steadfastly defending the social space in which individuals and groups can live out the dictates of their consciences, even when (especially when) those dictates have been rejected by the majority, we will bolster the long-term prospects for the liberty of conscience. It is not just about the individual and the state. There is important space in between.

Book Review: Commentary on Conflicts of Conscience in Health Care: An Institutional Compromise by Holly Fernandez Lynch

Conflicts of Conscience in Health Care was published in 2008 as the 24th volume in the Basic Bioethics series from the Massachusetts Institute of Technology. It is an American book dealing with the American political and legal controversies over freedom of conscience in health care. However, the discussion of the American experience by Holly Fernandez Lynch is relevant elsewhere, since the United States has the most extensive and varied network of protection of conscience legislation in the world.While acknowledging that freedom of conscience is of concern to all health care workers and institutions, Fernandez Lynch focuses exclusively on physicians. This carefully and deliberately restricted focus is one of the strengths of the book.After a preface and introduction, discussion and argument occupy about 260 pages, supplemented by 53 pages of end notes, many of which offer expanded comment on the text. A good 12 page index has been included, as well as four pages of cited statutes and cases. The earliest source found in a list of 300 references is from 1951; the rest date from 1972 to 2007.As the subtitle of the book indicates, the author is seeking a compromise that will provide maximal liberty for all parties. She believes that freedom of conscience for physicians and the provision of legal medical services are both important social goals, and that they are not incompatible. Quoting the Protection of Conscience Project, she affirms that all legitimate concerns can be met by dialogue, prudent planning, and the exercise of tolerance, imagination and political will.Fernandez Lynch advises readers to strive to at least take a neutral position and adopts this approach herself. She does not always succeed in this, but her effort has produced a book that is notably free of the self-righteousness and rancour one sometimes encounters in this debate. Regardless of their perspectives on the issues, readers will welcome many of the author’s trenchant observations. Her extensive discussion of practical issues is commendable, and she offers what appear to be novel suggestions. However, an attentive reading must take into account the effects of two underlying elements: some form of anti-religious prejudice, and dogmatic moral pluralism.Further, the author warns that her book is not about moral philosophy; she wants to leave philosophy to philosophers. It is sufficient, for her purposes, to solve the problems freedom of conscience is causing in modern health care. Thus, the book explains how to help patients obtain services when some of the physicians who control access to them are uncooperative. It is not a book about freedom of conscience. The problem with this approach is that we cannot know whether or not what the author proposes will safeguard freedom of conscience if we do not know what it is. Nonetheless, the author has been remarkably successful and the strategy she proposes is promising. Within the context of a book about patient access to services, she has offered arguments about the importance of freedom of conscience that are accessible and that many people will find convincing.

Beyond Politics: A Social and Cultural History of Federal Healthcare Conscience Protections

The day before the inauguration of his Democratic successor, President George W. Bush oversaw the promulgation of an administrative rule that extended “sweeping” new conscience protections to healthcare providers, one which would allow them to refuse to participate in or refuse to refer for medical services to which they morally or religiously object. Enacted in a funding regulation through the Department of Health and Human Services (“HHS”), the rule – commonly called the Provider Conscience Regulation (“Regulation”) – purported to clarify and implement existing federal law; by its own terms; however, the Regulation pushed the boundaries of those laws, granting protections to a broader class of individuals and across a wider range of services. In so doing, the Regulation sought to resolve an ongoing tension between patient access and provider autonomy, yet it served to reignite a long-standing debate over the proper role of morals in medicine.