For Students
While intended primarily for medical, pharmacy and nursing students, what follows may be of assistance to others studying for a career in health care or practitioners already in the field.
Table of Contents
I. IntroductionII. Identify objectionable procedures
III. Articulate the basis for your objections
IV. Establish the extent of your objections
V. Know the science
VI. Distinguish between philosophy and science
VII. Know relevant university policies
VIII. Know relevant policies of the profession
IX. Know human rights law
X. Know freedom of information law
XI. Be alert
XII. Be respectful
XIII. Respond appropriately to signals of unease
XIV. Defuse confrontation
XV. Begin by listening
XVI. Don't be in a rush
XVII. Be cautious if thinking out loud
XVIII. Make notes of every incident
XIX. Obtain copies of critical documents
XX. Get help - early
XXI. Networking: doctors and nurses without borders
XXII. Media: look before you leap
XXIII. The Protection of Conscience Project
I. Introduction
Conflicts of conscience can arise for a variety of reasons and in a variety of circumstances in nursing or medical practice, just as they arise in other walks of life. We are concerned here, however, not with working through ordinary ethical problems, but with the exercise of freedom of conscience that may generate an adverse and even hostile reaction from persons in positions of authority, colleagues, patients, or special interest groups. The following recommendations are meant to assist medical and nursing students faced with this kind of conflict.Those who take issue with your position will most likely do so because they are working from beliefs and principles uncritically assimilated from the dominant social, legal and intellectual culture. You may have difficulty responding to them if you were raised in a similar environment, even if your religious or moral upbringing places you, in some sense, ‘outside the culture.’ Your religious or moral perspective may be sufficiently different from your colleagues to generate disagreement about ethics, but your philosophical or intellectual perspective may be so similar that you find yourself tongue-tied when attempting to explain your views.
Four points should be kept in mind throughout.
First: in an important sense, everyone is a believer. Everyone acts and lives according to some ultimate standard by which he distinguishes right from wrong. In this respect, an atheist is as much a believer as an observant Jew. To demand that someone surrender his religious or moral convictions and instead accept ‘the ethics of the profession’ does not exclude belief; it suppresses one kind of belief and replaces it with another. Absent the demonstrable moral superiority of the members of the profession, there is no valid reason to submit to this kind of coercion. [There Are No Secular Unbelievers] [The Illusion of Moral Neutrality - Part IV] [Establishment Bioethics]
Second: the sciences that deal with material reality are not the only sources of knowledge, and certainly do not produce what is essential for the realization of human happiness through the correct ordering of society and human relationships. Love, justice, mercy, solidarity, wisdom and other virtues will make the most unscientific society a happy one, while the most scientific society will be rendered miserable by their absence.
Third: conscientious objection is a means by which a practitioner can preserve his own integrity by refusing to facilitate or participate in an immoral act. It is not a means to control the conduct of the patient or convert patients or colleagues to one’s views.
Finally: the following recommendations are not exhaustive, and they should be adapted to your circumstances, experience and personality.II. Identify objectionable procedures
As a first step, you must identify practices, procedures, or services that may be expected of you, but to which you object for reasons of conscience. The most common controversies centre around issues at the beginning and end of life: abortion, contraception, euthanasia, assisted suicide. However, the morality of artificial reproductive technology and eugenic engineering is sharply contested, and you may also have concerns about research on human subjects. Students in some countries may have to consider what might be expected of them in relation to capital punishment, torture, or coercive interrogation of persons in state custody.III. Articulate the basis for your objections
Having identified morally problematic procedures or services, which you may be able to do with little difficulty, it is not prudent to rest a claim to conscientious objection upon a generic and undeveloped appeal to religious belief or freedom of conscience. You must articulate the basis for your objections. There are three reasons for this.First: even if the law in your jurisdiction recognizes freedom of conscience and religion, such freedoms are not unlimited in principle. Those who want to suppress freedom of conscience among health care workers are less likely to deny that freedom than to substantially restrict it. Thus, you must not only be able to identify a religious or moral basis for your objection; you must be prepared to argue that it is reasonable and possible to accommodate you.
Second: religious believers may find that nominal co-religionists do not share their judgement about the moral acceptability of a procedure. This can make it more difficult to credibly assert, for example, that "Christians do not do X" or "Muslims do not do Y", especially if the person opposing your views has some official religious status or authority. Additional complications arise within a denominational health care institution in this situation.
Third: people raised within a religious, moral or cultural tradition are more likely to live by their beliefs and principles than to analyse them. As a result, they may find it difficult to explain or defend them when pressed, even if those principles are solidly grounded in practical wisdom and tested by centuries of collective experience. They may also make contradictory or ill-founded statements when struggling to articulate their views. In consequence, they can lose credibility with colleagues or persons in authority, and significantly weaken arguments that might be made later in an appeal before an academic committee, a disciplinary hearing, or court case.
Carefully consider the religious doctrines or moral principles to which you adhere to ensure that you understand them correctly, can apply them in practical situations and can explain them to others. As a conscientious objector, you must develop your ability to communicate with people who do not share your views, or who actively oppose them. Listen carefully to opposing arguments and prepare effective responses.IV. Establish the extent of your objections
An important reason for reflecting carefully upon how to apply your religious or moral convictions is that you must determine what kinds of actions would compromise your personal integrity. Some people consider themselves morally culpable only if they are direct participants in an immoral act, and do not object to referring a patient to someone willing to do what the patient wants. Others believe that it is immoral to facilitate a wrong by referral or other forms of assistance. [Referral: A False Compromise] Conflicts frequently arise with respect to referral and the provision of some kinds of information, so you must determine, in advance, how you will approach these issues. You must also consider how you will respond when in doubt about significant facts or moral issues, particularly when life or health is imminently at risk.Religious and ethical traditions frequently offer principles or guidelines to assist with moral reasoning. Be sure that you are aware of them, and be prepared to look to the insights offered by other traditions to supplement your own.
V. Know the science
Sound moral or ethical reasoning depends upon a complete and accurate grasp of relevant facts. For example: one cannot discuss the morality of embryonic stem cell research without a correct understanding of human embryology, and conscientious objection to euthanasia ought to be informed by adequate knowledge of palliative care. You may not be able to master all of the literature on a given subject, but you should take care to inform yourself fully about critical issues or points of contention. Demonstrate appropriate academic discipline and intellectual honesty in your adherence to or rejection of research findings. [Science, the Formation of Conscience and Moral Decision Making]VI. Distinguish between philosophy and science
Academic discipline requires an ability to distinguish between what lies within the province of science and what lies elsewhere. "Personhood" can have distinctive philosophical or legal meanings, but it is not a scientific concept at all. Whether or not something "ought" to be done is a subject for philosophy, religion, or ethics - not science. [Scientific and Philosophical Expertise: An Evaluation of the Arguments on "Personhood"]It is quite appropriate to challenge moral reasoning that is based upon erroneous science. But you should not tolerate bullying by professors, preceptors or colleagues who attempt to dismiss your moral convictions on the specious grounds that they are ‘unscientific’; their own moral convictions are equally unscientific, and cannot be otherwise.
VII. Know relevant university policies
Universities ought to have fairly extensive policies on evaluations of academic progress and of preceptorships. These policies should set out, in general terms, how the evaluations are to be done and how they may be appealed. A description of the appeal process ought to include the manner in which an appeal is to be launched, the stages through which it progresses, and the times within which each stage must be completed. Ideally, the policies will also set out the composition of the various committees or bodies hearing the appeal and the rights of students with respect to representation at the hearings. You should review these policies and ensure that you understand them and know how to access them.VIII. Know relevant policies of the profession
Professional colleges and associations have codes of ethics and policies that touch on issues of concern to conscientious objectors. For example: the Canadian Medical Association does not require referral for morally controversial procedures. Obtain copies of these policies and study them. Pay particular attention to the policies of regulatory bodies like Colleges of Physicians, which have disciplinary and licensing authority, but do not ignore the policies of specialist associations that may have considerable influence in setting ‘standards of care.’IX. Know human rights law
You cannot be expected to master human rights jurisprudence, but you should read the statutes governing human rights law in your jurisdiction and make copies of relevant sections. Be aware that statutes are interpreted by courts in decisions that are reported in "case law," and that a full understanding of the law requires knowledge of these cases. You are unlikely to have time for that kind of research. If a question arises about the application of part of a human rights statute to your case, you might begin by seeking help from a friend who is studying law. You might also be able to consult a paralegal service provided by a university law school, unless you believe that it may be unsympathetic or even hostile. If the issue is important or complicated, consult a lawyer.X. Know freedom of information law
Many jurisdictions now have freedom of information statutes that give citizens the right to access any information about them held by state or institutional authorities. Depending upon the wording of a statute, such a law might be used to force the university to disclose any information it has in its files concerning you, including ‘confidential’ internal memos and e-mails. If there is a freedom of information law in your jurisdiction, obtain a copy of it and find out whether or not it applies to the university. You may be able to get this information easily if the university has a privacy or freedom of information officer responsible for complying with requests for disclosure.XI. Be alert
Having identified your concerns, you must be alert to any suggestion or inference that someone who can adversely affect your professional or educational standing has taken unfavourable notice of your views. The first indication could be as blatant as an expletive-filled remonstrance, or as subtle as a questioning glance. You must be on the lookout for any sign of approaching difficulty in order to take all appropriate steps to protect yourself.XII. Be respectful
Some objectors encounter problems primarily because of the way they communicate with patients, colleagues or others. If it is necessary to explain your position, do so in a way that refers to your own moral responsibility, not that of your patient or colleague. Avoid expressions that impute wrongdoing to others or that might come across as "preaching".XIII. Respond appropriately to signals of unease
Conscientious objection is likely to make colleagues who do not share your views uncomfortable because it implies that what they are doing is wrong. It is unwise to increase their discomfort by making statements that will be perceived as questioning their moral judgement, as they are then likely to become hostile. Take note of their discomfort - ."You seem troubled/ disturbed/surprised" - and invite dialogue - "Have I offended you?"This approach expresses concern for the other person and respect for his sensibilities, while providing an opportunity for discussion.
You should not become hypersensitive to what others might be thinking, since that will only cause needless anxiety. On the other hand, one should not ignore clear signals that something is amiss. Your ability to read those signals will depend upon how well you know the other person and your own experience. If in doubt, remain silent, but make a note of the incident. If a problem is developing, your notes will probably make it apparent to you in time.XIV. Defuse confrontation
In addition to discomfort, you may encounter a belligerent challenge, contempt or condescension. If you are taken by surprise or find yourself flustered, no harm is done by admitting the fact and suggesting that you and your interlocutor should make time for an uninterrupted chat. If it is possible to make time for it then and there, do so. However, don’t rush into what might prove to be a contentious discussion simply because you feel the need to counter an offensive or ill-timed remark. You will do yourself and your colleague a favour by giving yourself even a few minutes to reflect and relax.XV. Begin by listening
Resist the urge to explain or defend yourself. Instead, ask your interlocutor to explain his concerns. Listen carefully, and ask questions, not to challenge his views, but to clarify the issues and identify any unexamined presuppositions that are governing his approach to them. This will give you the opportunity to settle some butterflies, organize your own thoughts and build your confidence. It should also diminish any antagonism felt by your critic, since he will see that you are listening to him and taking his concerns seriously. He may even feel that he is making a significant impact on you.Nonetheless, the most important reason to begin by listening is that you cannot respond effectively if you do not know what case you have to answer. There is no point exasperating a colleague by attempting to argue from incorrect assumptions about what he knows or believes. Let him tell you. Identify points of agreement and points of contention, and work together from there.
The notion of working together with your critic is important. The goal is authentic and respectful communication, even if it involves serious argument and fundamental disagreements.XVI. Don’t be in a rush
If you are uncertain about how to reply to facts or an argument presented by your critic, you should simply admit it and promise to continue the discussion after you have had time to think further about it or research the problem. Offer your critic the same courtesy, unasked for, if need be. There is no need to resolve everything at once. In fact, it may prove difficult to resolve even preliminary matters in the first encounter.XVII. Be cautious if ‘thinking out loud’
When serious discussion generates enthusiasm for enquiry you may find yourself ‘thinking out loud’ as you attempt to tease out the strands of your critic’s argument or consider the significance of a fact he raises. When the issue is conscientious objection, this ordinarily harmless habit should be avoided, especially in conversation with persons in authority. If you sincerely say "A" to one person, and, upon reflection, later revise "A" to "B," you may be accused of duplicity or irrationality, or characterized as someone who doesn’t know what he believes. Better to consider the issue privately or with the assistance of an ally than to speak to it prematurely.XVIII Make notes of every incident
Make detailed notes each time you encounter criticism or questions about your views, even if the incident seems minor or unimportant. The real significance of an innocuous question in September may not become apparent until after a clash in February. You will never regret recording information, but you will certainly regret not having done so.Do not rely on your memory even in the case of encounters that you are sure you will never forget. An appeal to an academic committee may not be heard for months; cross-examination before a court or human rights tribunal could come two years afterward. You will not accurately recall what was said unless you make notes of it at the time. Moreover, if the other parties to the incident made notes and you did not, it is probable that their accounts of what took place will be given much greater weight than yours.
If you cannot make detailed notes at the time or immediately afterward, make what notes you can, and expand them at the first reasonable opportunity that day. See Making Notes for a detailed discussion of note taking.
You can use a hand-held tape recorder to make your notes, whether in short or expanded form. You should then transcribe the notes. Transcription will put the notes into a form that can conveniently be used by others and will prevent them from being lost by erasure or damage. However, transcription is time-consuming, so you should not procrastinate. You will not want to be struggling to transcribe eight or nine hours of tape while studying for your final exams and preparing an appeal of your evaluation.
XIX. Obtain copies of critical documents
You should initial each page of an evaluation, memo or other document that refers to your conscientious objection. Initial below the last entry on each page or section, or strike a line from the last entry to the bottom of the page or section and initial there. Obtain a copy of the initialled document. This will prevent it from being changed later.If university authorities refuse to give you a copy of the document, advise them that you believe that you are entitled to it because it is your information. Tell them that you would rather not mobilize the student body in support of students’ right of access to their information, and would like to avoid a court confrontation to compel its release. This may result in a hurried conference and the making of "an exception" in your case, especially if the university policy violates freedom of information laws in your jurisdiction. If it does not, consult your contacts within the profession. If your university has a law school you may be able to access some form of para-legal assistance through senior students there; otherwise, see a lawyer.
XX. Get help - early
It is important to connect with like-minded colleagues in the university so that you can discuss problems as they arise. It is even more important to remain in contact with sympathetic people already active in your chosen profession, as their experience and knowledge of its administration will likely be invaluable if you run into trouble. Seek their advice and assistance as soon as you encounter any significant criticism. When approached by a student in difficulty, the Protection of Conscience Project will immediately facilitate contact between the student and professionals who are willing to assist.If you encounter opposition, criticism, unfair evaluations or other forms of repression from university authorities, professors or preceptors, do not assume that you will be able to work things through on your own, especially if you have to launch an academic appeal. You should seriously consider seeking legal advice if you encounter significant opposition. A failure in a key preceptorship or subject may nullify everything else you have accomplished. The harm done by losing an appeal at the first level may prove very difficult to undo in subsequent appeals or even through civil litigation.
XXI Networking: doctors & nurses without borders
Anti-religious secularists often try to banish religion from the public square by claims that religious beliefs are intrinsically divisive and encourage differences that lead to violence. The example of friendly collaboration in matters of mutual interest among people of different faiths, disciplines and backgrounds provides a practical and powerful counter-witness to such assertions. This is one of the reasons that the Project Advisory Board consists of scholars from different disciplines and different faiths, including Judaism, Catholic and Protestant Christianity, the Latter Day Saints and Islam.Long before a crisis looms you should seek the fellowship of students and professionals from other religious traditions (or none) who have a common interest in securing freedom of conscience in health care. You may be surprised to find that someone from a completely different faith and culture is more supportive of your views than a co-religionist who lives down the street.
If your university has a medical school, it may well have a law school and departments of philosophy and political science. You may find friends and supporters in all of these faculties.XXII Media: look before you leap
Be cautious if you are approached by the media, as media reports may well complicate resolution of your difficulty. The ‘friendly’ reporter may skewer you, or his editor may mangle story by cutting or changing it for publication . More commonly, the media often highlight controversy (conflict sells) and polarize opinion by simplistic reporting that fails to make appropriate distinctions or identify important issues. ‘Advocacy journalism’ from any perspective is potentially problematic;‘friendly fire’ kills, too.Television and radio interviews present particular problems because a lengthy interview may yield a five second sound bite unrepresentative of the discussion. These ‘bites’ can be sandwiched between other visuals or commentary to produce unpleasantly surprising results. It is also extraordinarily difficult to successfully convey a philosophical or moral argument on television because pictures - the very essence of TV journalism - are better at communicating emotion than logical thought.
You should not agree to an interview unless you are quite sure how much of the case you are prepared to discuss. If there are things that you don’t want to talk publicly about, be sure that you can explain the reason(s) for your reticence to the reporter in advance. For example: you might think it safe to explain the principled basis for your objections, but not to discuss what took place between you and your colleague, preceptor or patient because of a pending review or hearing. If you attempt to pick and choose the questions you will answer, it is likely to appear that you have something to hide or are unsure of yourself. Do not answer a question with, "No comment." If you choose not to answer a question, explain why you cannot answer it.
Do not attempt to direct a reporter as to what angle he should take in a story or what he should write. Never ask a journalist to let you review his story before publication. Most will refuse, many will have nothing more to do with you, and not a few will make you the target rather than the subject of a column or editorial.
Reporters frequently tape record interviews, but are not obliged to notify you of the fact. Don’t ask if you are being recorded (the question suggests you have something to hide) but assume that any conversation with a reporter is being taped. You may record your conversations and interviews with reporters, but always tell them you are doing so. One journalist consulted by the Project commented, "Your recording will keep an honest reporter honest, and scare the dishonest one straight."
If surprised by a call from a reporter, take his name and contact information and call him back after you have settled your butterflies and considered your position. If you are not certain that you should speak to the media, do not do so. An unsolicited request for an interview can be courteously turned aside with the explanation that you hope to resolve the problem through the channels open to you, and you don’t wish to complicate matters by speaking publicly. A good reporter will accept this, but will also try - politely - to get you to say something, perhaps in response to a hypothetical question. Don’t take the bait. Take the reporter’s name and contact information and tell him that you will call should you decide to speak publicly later on.
If, after an interview, you realize that you have made an error or believe that you didn't express yourself clearly, call the reporter to clarify your comments or correct your mistake; better to be considered sincerely mistaken than carelessly ignorant.
Beware of suggestions that you should ‘go public’. Speaking to the media to garner sympathy or support for your position should only be attempted after careful consideration and consultation; it is normally inadvisable. Fear that you might launch a media initiative may encourage compromise by your opposition; a failed media initiative will only solidify their intransigence.
Conscientious objectors usually form a minority within a profession and the public at large, so even if the media take up the story and people take notice, it is likely to generate as much opposition as support. Moreover, opponents of freedom of conscience in health care tend to be well-funded and well-connected with media, government and the professions. Media attention may cause them to launch a campaign against you, and you may be hard-pressed to counter it.
Another point to consider is that the media, politicians and many members of the professions tend to be dismissive of anything to which a pro-life label is attached. If your objection concerns a pro-life issue, you will be able to secure the support of the pro-life community, but that may carry very little weight with the wider public or those handling your case, and may actually inflame prejudice against you.
If there is an internal review or appeal process available to you, that is the first place to make your case. You are likely to undermine your credibility if you appear to be seeking a verdict through the media rather than in the proper forum. Media reports, especially those that contain misquotes or other inaccuracies, can come back to haunt you during an academic appeal or judicial proceeding. You may find yourself being asked to explain something that you did not say, or (worse) something that you did say that was reported out of context, or (worst of all) something you regret having said that was not only accurately reported, but captured on tape.
Despite all of these arguments against ‘going public’, there are times when it may be productive to do so. For example: if the university were to refuse to give you a copy of your evaluation or some similarly important document, it is likely that most students would support your right of access, even if they disagreed with your ethical stance. In that case, however, one would highlight the issue of freedom of information, not conscientious objection.
Of course, not all media are hostile or unfair, and sometimes media attention can favourably influence the course of events. By all means, collaborate with others to develop a media strategy, but keep it in reserve until it is clear that it can be implemented safely and effectively. It might be prudent to first break the story with potentially sympathetic outlets or reporters who (one hopes) will report it fairly and accurately.
However, once you ‘go public,’ even with someone you think trustworthy, you will have no control over how the media handle the story. That is one of the reasons your opponents may be willing to compromise to avoid public exposure. They can’t control the media, either.XXIII. The Protection of Conscience Project
The Victim Wordksheet on the Project website can be downloaded or completed on-line. It is meant to help you to obtain and organize information pertaining to your case. Completing the survey before you see a lawyer or other professional will provide you with much of the information he may require in order to assess your position.Use the Project website to obtain arguments and information relevant to your situation. Contact the Project Administrator if you cannot find what you need, or if you are encountering coercion or discrimination. Every effort will be made to provide you with support and assistance. The service is limited, but it is free.
Even if it had the resources, the Project has no standing to intervene with university authorities or appear before a tribunal hearing your case, but it may be possible to prepare a report on the matter. The report will be given to you, to be used in accordance with the rules of evidence in your jurisdiction and as you or your counsel think best. It will not be further disseminated without your permission. With respect to Project reports, please bear in mind the following.