ABC Health Service Agency (Kansas, U.S.A.) (2001)

American Medical Association Policy H-295.896 Conscience Clause: Final Report

American Pharmaceutical Association Conscience Clause

Canadian Healthcare Association (Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care)

Canadian Medical Association (Induced Abortion)

Canadian Medical Association (Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care)

Canadian Nurses Association (Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care)

Catholic Health Association of British Columbia

Catholic Health Association of Canada (Joint Statement on Preventing and Resolving Ethical Conflicts Involving Health Care Providers and Persons Receiving Care)

Catholic Health Association of the United States

Christian Medical and Dental Associations (USA)- Health Care Right of Conscience

Christian Medical Fellowship (United Kingdom)

Islamic Medical Association of North America (Use of Physicians for Human Torture)

Nurses for Life (Canada)

Ohio Pharmacists Association Conscience Clause

Pharmacists for Life International Model Conscience Clause

Royal College of Nursing of the United Kingdom

APhA recognizes the individual pharmacist's right to exercise conscientious refusal and supports the establishment of systems to ensure patient access to legally prescribed therapy without compromising the pharmacist's right of conscientious refusal.

APhA shall appoint a council to serve as a resource for the profession in addressing and understanding ethical issues.

The Ohio Pharmacists Association adopted the following resolution at their meeting the weekend of 17/19 April, 1999.

Resolution 1-99
Whereas, There is a need for guidance from pharmacy organizations concerning the potential conflict between a pharmacist's duty to provide legal and medically indicated medications and their right to refuse to participate in something they find morally, religiously or ethically objectionable; and

Whereas, Many therapies (e.g., abortifacients, capital punishment, cloning, stem cell and gene therapy, physician-assisted suicide, temination of pregnancy, and termination of life support) may be morally , religiously, or ethically objectionable to a pharmacist: and

Whereas, The Joint Commission on Accreditation for Healthcare Organizations currently required accredited institutions to develop a policy allowing for conscientious objection by all healthcare employees, some of these policies are vague and do not address the specific concerns of pharmacists; be it

Resolved, That the Ohio Pharmacists Association supports a pharmacist's right to conscientious objection to morally, religiously, or ethically troubling therapies while protecting the patient's right to obtain legally and medically indicated treatments for them.
 

The rights of conscience of any person being a duly licensed pharmacist, who shall object on personal, ethical, moral or religious grounds to the performance of any act in the normal course of professional performance or dispensing, shall be respected.

Further, such a refusal to perform any act or the omission of any act based on such a claim of conscience, shall not form the basis for any claim for damages or any recriminatory or discriminatory action against such a person.

Any such person making such a claim of conscience, or who states a willingness or intention to make such a claim of conscience, shall not be denied employment, or discriminated against in any manner related to employment because of such a claim of conscience.

The 'Conscience' Clause

Introduction:

At no time has the Rcn made a policy statement on the rights or wrongs of abortion.  The decision as to whether or not an abortion should be performed is a medical one.  The role of the nurse is the undertaking of the nursing care of the woman receiving medical treatment.   The need for nursing care obviously exists but  it must always be remembered that nurses hold personal views and beliefs too, as do all members of the public and nurses have the same rights as other citizens.  The general public holds differing views on the rights and wrongs of abortion and nurses are no different.  Some will choose to undertake the nursing care of persons under going abortion and others will not.  It is the recognition of  the right of  nurses to 'choose' that has caused the Rcn concern  for many years.

In January 1972, in submitting evidence to the Committee on the Working of the Abortion Act (Lane Committee), the Rcn stated:

"The policy of the Rcn on this matter is that the decision to perform an abortion is a medical responsibility but where nurses are involved in the procedure, their FREEDOM TO DETERMINE WHETHER OR NOT THEY ARE PREPARED TO PARTICIPATE SHOULD BE RECOGNISED.  The principle applies to any issue which may involve a matter of conscience or religion; a nurse should not be required to perform any action or to assist in any procedure which is against her conscience or beliefs."

Any nurse has the right to refuse to take part in abortions on grounds of conscience.  Provisions are contained in Section 4 of the Abortion Act which reads:

4. (1) Subject to sub-section (2) of this Section, no person shall be under any duty, whether by contract or by any statutory or other legal requirements, to participate in any treatment authorised by the Act to which he has a conscientious objection:  provided that in any legal proceedings the burden of proof of conscientious objection shall rest on the person claiming to rely on it.

(2) Nothing in sub-section (1) of this Section shall affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.

It is quite clear, therefore, that a person who has a conscientious objection may LEGALLY REFUSE to participate in treatment authorised by the Act OTHER THAN in cases where such treatment is in what amounts broadly to an emergency when the treatment is necessary to save life or prevent grave permanent injury to the physical or mental health of the pregnant woman.

Interpretation of the problems arising from the 'Conscience' Clause
As early as 1995, the DHSS acknowledged the concern of nurses that the Clause (Section 4  (2)) was open to differing interpretations.  In a paper giving guidance to professional officers, the DHSS stated:-

"Section 4 (2) exists in the regulations primarily to obviate the delay which might occur in an emergency if  before treatment could be carried out, the statutory requirement of the signed agreement of the need for treatment by a second doctor be obtained.  It cannot therefore be taken as the exclusive indication of those cases where the conscience clause can be revoked... a nurse is capable of reaching a considered view as to what is a medical necessity.  The onus would be on a nurse who is sought to rely on the conscience clause to show that she did sincerely hold a conscientious objection to participating. Once she had done that, the onus would then be on anyone who sought to deny her right to show that the abortion had been necessary to save life or to prevent grave permanent injury."

It is the view of the Rcn that in normal circumstances any conscientious objection to participation in abortions would be conveyed to and documented by nursing management.  Trained nurses on gynaecological wards, in abortion units and in theatres would work there through choice.  Situations may arise when wards and theatres are staffed by relief nurses who have not been counselled and who have not informed nurse management of any conscientious objection to participation in abortions.  Technically problems should not arise since ward intakes and theatre lists will be known in advance and nurse management will be in a position to determine whether the relief staff might object or not.  The nurses too should state their case and alternative arrangements will need to be made by management.  Nurses not so prepared, have the right to refuse to participate in treatment authorised by the Act OTHER THAN in cases falling under Section 4 (2) of the Act.

It is reiterated here that even under Section 4 (2), the nurse can rely on the conscience clause on reaching a considered view as to what is a medical necessity.  On stating the objection, and documentation of the objection is advised, the onus is on management to make alternative arrangements.

Another problem is interpretation that has arisen as to whether the conscience clause covers pre-operative and post-operative care.  The legal opinion as outlined in the DHSS paper mentioned is that:

'This does include pre-operative nursing care because unless provisions of the Act are complied with such care will constitute aiding and abetting an offence under the law.  On the other hand, the legal view is that post-operative nursing care is not covered by the conscience clause because it is not treatment authorised by the Act.'

It is the view of the Rcn that nursing care is a continuous process and that therefore nurses who object to participation in abortion treatment should be facilitated by nurse management to non-participation in that continuous process.

Abortion by non-surgical methods
Abortion by non-surgical methods
When an abortion is carried out by a surgical technique it is the operating department nurses who are most closely involved. Non-surgical methods of abortion bring a new dimension to the nursing requirements of the patient because the nurse is involved with the care throughout the procedure, from admission, during the abortion, and after, until her transfer home.

All nurse learners and all nurses seeking appointment to a gynaecologic and/or theatre suite where abortions are carried out, require sympathetic handling. This will involve counselling and careful explanation of all aspects of abortion that includes the law and the conscience clause.  These nurses are required to be given the opportunity to contract out and this decision should be noted.  It is the view of the Rcn that nurse learners may 'change their minds' following clinical experience and the continuous counselling process should not be denied to them.

Whilst conscientious objectors have rights, women seeking abortions have rights too.  A doctor who objects should ensure that advice for the pregnant woman is available and this may require widening of the conscience clause.

Other comments of the Rcn
Distress can be caused to patients and staff when patients in hospital for sub-fertility investigations are nursed in wards with patients admitted for abortion.  This should not happen and the reasons in terms of standards of care are obvious.

Family planning advice should be provided as an integral part of the abortion treatment.  Increasingly family planning nurses (specialist nurses) are undertaking duties in gynaecological wards and midwifery units, but the service is by no means available everywhere.  Many family planning nurses are only employed on a sessional basis for clinic sessions.

The Specified period after which an abortion may not be carried out
According to the provisions of the Infant Life (Preservation) Act 1929, a foetus is viable after 28 weeks of pregnancy have passed. Medical termination of pregnancy can take place therefore if two registered medical practitioners are of the opinion -

1) that the continuance of the pregnancy would involve risk to the life of the pregnant woman or of injury to the physical or mental health of the pregnant woman, or any existing children of her family, greater than if the pregnancy were terminated; or

2) that there is a substantial risk that if the child were born it would suffer from such a physical or mental abnormality as to be seriously handicapped, up until the 28^th week of pregnancy.

In 1972, the Rcn called for a definite period to be specified after which abortion should not be carried out except to preserve the  life of the mother.  The Rcn felt that 12 weeks would be reasonable, but realised this could only be achieved if adequate facilities were available and if preventive measures were seriously entered into.  This has not occurred.

In 1978, the Rcn Society of Primary Health Care Nursing recognised that considerable advances had been made in the detection of severe foetal abnormalities in utero.  The Society also expressed concern over the increase in numbers of 'schoolgirl' mothers and expecially those who emotionally denied pregnancy and sought advice late in pregnancy.  The Society therefore conc1uded that in order to meet the needs of women carrying severely handicapped foetus's which could only be detected later in pregnancy, and facilitate their right to choose an abortion or not, the specified period of time should not be too restrictive.  The Society is of the view that the period of time should be a matter of medical advice to the legislators.

For mid-trimester abortions Prostaglandin E2, marketed under the name Prostin E_2, is used when the pregnancy is advanced to sixteen weeks or more. The procedure is carried out in hospital.  A premedication drug is given to the patient who will be examined in the operating theatre where a self-retaining catheter is inserted into the cervix above the level of the internal os.  A test dose of Prostin E₂ is given to the patient who is observed for any adverse reaction.  Prostin is then administered at a rate of about 100 micrograms per hour, either by infusion_, or by pump. Observation of the patient's pulse and blood pressure are made throughout the procedure.  Approximately six hours after the commencement of Prostin the infusion is ceased and Cyntocinon or a similar drug is given.  After this stage the catheter will leave the cervix and the products of pregnancy can be seen and removed.

The ward nurse's involvement will include taking a nursing history for the patient so that the nursing needs can be identified and planned.  A definite relationship between the nurse and the patient will have been forged and the nurse in conjunction with the other members of the team will be responsible throughout the patient's stay for carrying out any nursing procedures, as well as contributing to her emotional support.  Apart from the short visit to the operating theatre for the insertion of the catheter, the patient will be present in the ward throughout the procedure.  It must be reiterated that a nurse who wishes not to be involved with the care of a patient undergoing an abortion should make her views known as described above.

...............

Another problem is that of the nurse learner.  The Lane Committee recommended that abortion cases should be nursed in special units staffed by trained nurses where no nurses in training should work, and the Rcn has always supported this.  The need for special units is even more apparent today as medical advances have brought about a higher incidence of induction of labour and 'normal' delivery of the foetus.  Midwifery and possibly paediatric nursing skills are required in adequately providing appropriate care.

Such units rarely exist and the majority of abortions are carried out in gynaecologica1 wards to which nurse learners are allocated for experience. Such wards are often lacking in midwifery expertise or close communications with midwifery and paediatric units.

If nurses in training are to be allocated to wards in which patients undergoing an abortion are cared for, the students require preparation, counselling, sympathetic handling and careful explanation of the provisions of the Abortion Act.  Nurse learners must, of course, be given the opportunity to contract out of participation in abortion treatment on grounds of conscience.

Finally, the Rcn is aware that there is a reluctance on the part of some nurses to exercise their right to contract out on conscientious grounds because they consider that to do so would increase the pressure on their colleagues by adding to their workload.

CONCLUSIONS
The Rcn concludes that the conscience clause requires some strengthening, any objection there might be to participation in abortion treatment should be specified so that pressure to undertake work that is against moral, religious and ethical beliefs, for example, would be largely negated.  In order to offer the highest standards of care and at the same time assist to alleviate the stress on nurse learners and conscientious objectors, abortions should be carried out in special units or wards.

The CMA defines abortion as "the active termination of a pregnancy before fetal viability,"  and states that physicians should not be forced to participate in abortions.  Physicians who object to abortion for reasons of conscience are advised to inform their patients of their objections so that the patient can consult another physician.  The CMA stresses that physicians who decline to participate in abortion should not be discriminated against, and emphasizes the need to respect the rights of conscientious objectors, especially those in training for obstetrics and gynecology, and anesthesia.

The CMA declined to give permission for the Project to post a copy of the policy on the website.  The position statement can be accessed here on their website.
 

One of our objectives in Catholic health is to assist personnel to work within an ethical framework, characterized in the Health Ethics Guide, published by the Catholic Health Association of Canada. The Catholic Health Association of British Columbia has identified the need for leadership in the are of values conflict in the workplace and the need for the development of a framework for ethical reflection. We need to encourage personnel to examine how their moral lives integrate with their professional lives. We believe that doing so may lead to the creation of environments where more open discussion can happen.

We believe that the discussion of issues of conscience needs to become an accepted part of organizational life in health care. Administrators and management teams need to work to ensure that such discussions become part of the culture of the workplace. These dialogues are essential to allow health teams to work well in the workplace. While values conflicts are inevitable, we need to create supportive environments where dialogue can take place without fear of recrimination. We believe that allowing personnel to engage in such conversations will result in stronger teams that are better able to care for those we serve. This excerpt from the Health Ethics Guide, in the chapter on "Governance and Administration", addresses matters of conscience:

"No one may be required to participate in activity that in conscience the person considers to be immoral. While continuing to fulfill its mission, the organization is to provide for and to facilitate the exercise of conscientious objection without threat of reprisals. The exercise of conscientious objection must not put the person receiving care at risk of harm or abandonment."

CHABC believes that respect must be extended to all health care workers for the informed choices they make in providing care. At the same time, we must continue to adhere to the missions of Catholic health care to provide compassionate, professional care to every individual, regardless of religious beliefs. Health care personnel should not be forced to act against a deeply held moral conviction and religious belief that all human life is sacred and inviolable. Not only would this create inner conflict for them, it would create a conflict with the employer with resulting negative impact on service to patients and residents. believes that respect must be extended to all health care workers for the informed choices they make in providing care. At the same time, we must continue to adhere to the missions of Catholic health care to provide compassionate, professional care to every individual, regardless of religious beliefs. Health care personnel should not be forced to act against a deeply held moral conviction and religious belief that all human life is sacred and inviolable. Not only would this create inner conflict for them, it would create a conflict with the employer with resulting negative impact on service to patients and residents.

In Canada, there is currently no legislation to protect the rights of workers in matters of moral conviction and religious beliefs. There is, however, a bill that has been introduced to amend the Criminal Code (Bill S-11, sponsored by B.C. Senator Ray Perrault). This Bill proposes to protect the rights of health care providers who refuse to participate in surgical or medical treatments that are contrary to their moral conviction or religious belief recognizing the sacredness of human life, without fear of reprisal or other discriminatory coercion.

CHABC supports Senator Perrault’s efforts in this regard. At the same time, we encourage health care personnel to engage in responsible and rational discussions with the appropriate people in their organizations with respect to decisions of conscience. Ideally, it would be best to create non-legislative and non-confrontational opportunities to deal with moral and religious conflicts that may arise in the health care workplace.

We acknowledge CHABC as a source of information for this statement.

November, 2000
Reproduced with the permission of the Catholic Health Association of B.C.

CMDA- Double Effect

Healthcare Education
and Christian Faith

Respect for conscientiously held beliefs of individuals and for individual differences is an essential part of our free society. The right of choice is foundational in our healthcare process, and it applies to both healthcare professionals and patients alike. Issues of conscience arise when some aspect of medical care is in conflict with the personal beliefs and values of the patient or the healthcare professional. CMDA believes that in such circumstances the Rights of Conscience have priority.

Patient’s Right of Conscience:
The right of competent patients on the basis of conscience to refuse treatment, even when such refusal would likely bring harm to themselves, should be respected.

The right of competent patients on the basis of conscience to refuse treatment, when such refusal would likely threaten the health and/or life of others, should be resisted and should become a matter of public interest and responsibility.

The right of a healthcare surrogate on the basis of conscience to refuse treatment, thereby threatening the health and/or life of another, should be resisted and should become a matter of public interest and responsibility

The Healthcare Professional’s Right of Conscience
All healthcare professionals have the right to refuse to participate in situations or procedures that they believe to be morally wrong and/or harmful to the patient or others. In such circumstances, healthcare professionals have an obligation to ensure that the patient’s records are transferred to the healthcare professional of the patient’s choice.

Healthcare institutions have the obligation to disclose the services they would refuse to give.

Healthcare institutions should not lose public funding as a result of exercising their right of conscience

Healthcare professionals at all levels should seek to learn about and understand policies and procedures that they deem morally objectionable.

No organization or governing body should mandate participation in policies or procedures that violate conscience.

See statement on Moral Complicity with Evil.

Approved by the House of Representatives June 11, 2004 53 approvals; 2 abstentions. 

CMDA- Double Effect

Healthcare Right of Conscience

Healthcare Education and Christian Faith 
Reproduced with permission

Education in the healthcare professions presents particular challenges in combining education, the profession and the care of the patient. Christians in healthcare education should look to their faith for support and guidance in addressing these issues.

Healthcare Trainees
Medical and dental students and residents are partially trained healthcare professionals. Christian healthcare trainees are subject to the same standards and guidance as are fully trained Christian healthcare professionals (see Standards For Life*)

All authority is established by God. Healthcare trainees should respect the authority of attending clinicians and others responsible for patient care. In situations where there is a difference of opinion between a trainee and those professionals in authority, excluding matters of conscience, the trainee should respectfully state his or her opinion and reasons, and should then honor the final decision of the person in authority. If the trainee believes a patient may be harmed by the decision, he or she should tactfully seek counsel from one or more experienced professionals.

Professional trainees should not place a patient at physical risk for the sake of learning, but should seek supervision from others with more experience or knowledge, when appropriate. They should not put themselves at moral risk, but rather graciously decline to participate in any aspect of training or patient care which would violate their conscience. . .

If a trainee in the healthcare professions expresses an unwillingness to participate in an aspect of training or patient care as a matter of conscience, that stance should be explored in a non-judgmental manner to ensure that both parties fully understand the issue. The trainee's position on matters of conscience should be honored without academic or personal penalty. . . [Full text]

When may a general practitioner
 refuse to accept a patient?

Conscientious objection and
referral

Maintaining trust in the
 profession / expressing
personal beliefs

Differences of View about best interests (para 9)

Q5. In your experience, how effective is independent clinical and/or ethical review in helping to reach a consensus in such cases?

Independent reviews are more likely to be effective in reaching a consensus in cases of disagreement if they are easily and quickly attainable from people with extensive clinical experience, recognised integrity and the willingness to explain decision pathways. It is important that in the light of paragraphs 19 (senior clinician decides) and paragraph 40 (non-compliers answering to courts and GMC) that junior members of the health-care team are not forced to implement non-treatment decisions against conscience. A conscientious objection clause needs to be added here to ensure that such people are not discriminated against.

Original Article & Links

'Human Bodies, Human Choices - The Law on Human Organs and Tissue in England and Wales
Submission to the Department of Health, 14 October, 2002  (United Kingdom)

15I. A provision for conscientious objection is essential to ensure that doctors and other health professionals who wish to abide by the Hippocratic Oath and Declaration of Geneva should not be discriminated against or stigmatised.