Conscientious Objection In Healthcare Research Articles

Quotas: Enabling Conscientious Objection to Coexist with Abortion Access

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise—a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.

The Problem of "Core Moral Beliefs" as the Ground of Conscientious Objection.

Mark Wicclair's defense of conscientious objection is grounded in an effort to respect the core moral beliefs of health care providers. While such a theoretical schema has merit, this paper argues that core moral beliefs should not serve as the basis of conscientious objection in health care because we, as a community, lack reliable access to a person's core moral beliefs and because individuals are prone to be confused about the scope and extent of their core moral beliefs. Furthermore, a person's confusion over their core moral beliefs is likely to be exacerbated when they lack time to investigate those beliefs and are under heightened external pressure to do so-both conditions frequently encountered by health care providers. Finally, the paper considers whether grounding conscientious objection in core moral beliefs might have the unintended consequence of further entrenching the practical problems that the move is aiming to solve.

Conscientious Objection in Healthcare: Neither a Negative Nor a Positive Right

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.

Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests

Conflict of interests (COIs) in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner’s financial interest conflicts with patients’ interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of “interests” cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners’ moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs.

A Matter of Conscience: Examining the Law and Policy of Conscientious Objection in Health Care

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 and systemic injustice

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 conscientious objection should be allowed so as to prevent cases of systemic injustice.

Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and...

Selective Conscientious Objection in Healthcare

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 objects to one abortion but not to another, depending on the circumstances. I consider not only objections to abortion, but also objections to the withdrawal of life-saving treatment at the request of a competent patient, which is almost always selective. I explore how the objector might articulate the selective objection, and what impact it might have on the patient, within the conceptual space of relevant statutes and professional guidelines.

Conscientious Objection and Clinical Judgement: The Right to Refuse to Harm

This paper argues that healthcare aims at the good of health, that this pursuit of the good necessitates conscience, and that conscience is required in every practical judgement, including clinical judgment. Conscientious objection in healthcare is usually restricted to a handful of controversial ends (e.g. abortion, euthanasia, contraception), yet the necessity of conscience in all clinical judgements implies the possibility of conscientious objection to means. The distinction between conscientious objection to means and ends is explored and its implications considered. Based on this, it is suggested that conscientious objection, whether to means or ends, occurs when a proposed course of action comes into irreconcilable conflict with the moral principle ‘do no harm’. It is, therefore, concluded that conscientious objection in healthcare can be conceived as a requirement of the moral imperative to do no harm, the right to refuse to harm in regard to health.

Acceptable attitudes and the limits of tolerance: Understanding public attitudes to conscientious objection in healthcare

BackgroundThe public’s attitudes to conscientious objection (CO) are likely to influence political decisions about CO and trust towards healthcare systems and providers. Few studies examine the pub...

Percepción del alumnado de medicina sobre la objeción de conciencia a la interrupción voluntaria del embarazo en Galicia

ObjectiveTo discover whether future doctors in Galicia (Spain) are willing to express conscientious objection to voluntary termination of pregnancy (VTP). The medical students’ level of knowledge regarding conscientious objection in health care was also examined, and their knowledge regarding the costs patients would incur if unable to exercise their right to VTP. MethodCross-sectional study by conducting a survey of 350 medical students in the 2nd and the 5th years of the Degree in Medicine at the University of Santiago de Compostela, in the academic year 2017-2018. Results70.8% of those surveyed would not declare conscientious objection to VTP. In addition, 70% believe that conscientious objection to VTP can have negative consequences for pregnant women if they are referred from public to private healthcare. However, 72.9% support physicians having the right to declare their conscientious objection to VTP. ConclusionsThe problem of referring pregnant women to private healthcare, as a consequence of conscientious objection to VTP, is presented as critical in Spain, and in Galicia in particular. The future physicians showed that they strongly favoured not objecting to this healthcare practice, which will enable the problem to be resolved in the near future.

Discriminatory Conscientious Objections in Healthcare: A Response to Ancell and Sinnott-Armstrong.

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.

Public reason in justifications of conscientious objection in health care.

Current mainstream approaches to conscientious objection either uphold the standards of public health care by preventing objections or protect the consciences of health-care professionals by accommodating objections. Public justification approaches are a compromise position that accommodate conscientious objections only when objectors can publicly justify the grounds of their objections. Public justification approaches require objectors and assessors to speak a common normative language and to this end it has been suggested that objectors should be required to cast their objection in terms of public reason. We provide critical support for such a public reason condition and argue that it would be neither too demanding nor too permissive. We also respond to objections that it unfairly favours secular over religious objectors and that public reasons cannot be held with the kind of sincerity thought to characterize conscientious objections.

Reasonable Accommodation of Conscientious Objection in Health Care Is Morally and Legally Required

While mainstream, establishment medical journals have published opinion pieces condemning conscientious refusals in medical care, American law has consistently and repeatedly supported a right to such refusals. Law has not relied on a particular philosophical basis for health care. Indeed, legal precedents reject any monolithic model, whether based on consumerism or on professional obligations. Law focuses on the coexistence of diverse understandings, motivations, and delivery models. Scholarly approaches tend to ignore the fact that, fundamentally, conscientious objection involves a minority telling the majority that the objector(s) cannot ethically participate according to the majority's preferred model or set of rules. Religious liberty is protected in the US by applying strict scrutiny. Any governmental burden on religious liberty must further a compelling governmental interest and be implemented using the least restrictive means reasonably available. After years of scholarly controversy, strict scrutiny continues to be the law. The moral basis for the legal right of conscientious objection has been affirmed and expanded by Hobby Lobby in 2014, outlined in an Attorney General Memorandum in 2017, and codified in a Final Conscience Rule by the Department of Health and Human Services in May 2019.

Conscientious objection to intentional killing: an argument for toleration

BackgroundIn 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.Main textThis 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.ConclusionThere 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.

Justifying Conscience Clauses.

In "Disentangling Conscience Protections," in this issue of the Hastings Center Report, Nadia Sawicki offers a taxonomy of conscience protection laws (conscience clauses) that highlights the expansive protections they can offer to health professionals who refuse to provide a medical service for reasons of conscience. Conscience clauses can protect health professionals from adverse actions by public actors (such as administrative agencies, prosecutors, and government funders) or private actors (such as employers, private professional associations, and injured patients), and they can also protect health professionals from being subject to adverse actions for their beliefs, their conduct, or harm that results from their conduct. This taxonomy provides an accurate description of the broad range of protections conscience clauses can offer and thereby is a valuable contribution to the scholarly literature on conscientious objection in health care. But it remains to consider whether the distinctions Sawicki identifies disentangle conscience protections beyond merely providing a taxonomy. In particular, does the taxonomy identify relevant distinctions in relation to determining whether a conscience clause is justified?

Conscientious objection in healthcare: How much discretionary space best supports good medicine?

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.

A Defense of Conscientious Objection in Health Care

In this essay, I defend rights of conscientious objection against various objections raised on deontological grounds of rights and entitlements as well as on consequentialist, utilitarian grounds. Udo Schuklenk and Ricardo Smalling in their article, “Why Medical Professionals Have No Moral Claim to Conscientious Objection Accommodation in Liberal Democracies” raise various objections, including the Objection from the Rights of Patients, the Objection from Monopoly, the Objection from Religion, the Objection from Untestability, and the Objection from Inconsistency. This article also responds to the concern about “unconstrained conscientious objection.” It suggests that we can distinguish legitimate from illegitimate conscientious objection in part by means of distinguishing objection to particular kinds of procedures from objection to treating particular kinds of persons. Perhaps the most promising way of differentiating legitimate from illegitimate conscientious objection in healthcare is by means of the goal of the medical art understood as the promotion of health.

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).

Professional and conscience-based refusals: the case of the psychiatrist's harmful prescription

By way of a case story, two common presuppositions in the academic debate on conscientious objection in healthcare are challenged. First, the debate typically presupposes a sharp division between conscience-based...