Project Logo

Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Blustein J. Doing what the patient orders: maintaining integrity in the doctor-patient relationship.  J. Bioethics. 1993 Jul;7(4):290-314.PMID: 11651605

Jeffrey Blustein

  • No profession has undergone as much scrutiny in the past several decades as that of medicine. Indeed, one might well argue that no profession has ever undergone so much change in so short a time. An essential part of this change has been the growing insistence that competent, adult patients have the right to decide about the course of their own medical treatment. However, the familiar and widely accepted principle of patient self-determination entails a corollary that has received little attention in the growing literature on the ethics of physician-patient relations: if patients are to direct the course of their own medical treatment, then physicians are at least sometimes to be guided in their actions on behalf of patients by values that are not, and may even be incompatible with, their own values. Unless it is supposed that it would be best if physicians were simply to accommodate any and all patient requests, a possibility I consider and reject in this paper, there are bound to be numerous instances of legitimate moral conflict between the preferences of physicians and patients. In this paper, I examine the implications of this sort of moral conflict from the standpoint of the integrity of the physician.

Brushwood DB. Conscientious objection and abortifacient drugs. Clin Ther 1993 Jan-Feb;15(1):204-12; discussion 168  University of Florida, Gainesville. PMID: 8458050

D.B. Brushwood

Abstract:  The legal right to assert a conscientious objection is reviewed, using as an example the dispensing of abortifacient drugs by pharmacists. The three areas of law that most significantly concern the right to assert a conscientious refusal are employment law, conscience clauses, and religious discrimination law. Each of these is reviewed, with descriptions of recent cases. It is concluded that employment law protects refusals that are consistent with public policy, but does not permit an employee's personal policy to determine how a business will be run; that conscience clauses appear to provide protection for pharmacists who object to dispensing abortifacients, but that the precise meanings of critical words and phrases in some clauses need to be defined; and that even though laws of religious discrimination require that employers accommodate religious beliefs, they may not protect a pharmacist who objects to dispensing abortifacients if the accommodation becomes unreasonably burdensome.

Curtin LL. Creating moral space for nurses. Nurs Manage 1993 Mar;24(3):18-9  PMID: 8455888

Leah L. Curtin

  • Three critical care nurses in Michigan worked together efficiently as they resuscitated an irreversibly dying man. All the while, tears ran down their cheeks. This man had suffered for weeks. He had begged them to let him die. But there were orders and policies, and ...

A delivery room nurse in California was accused of attempted manslaughter because she obeyed a "verbal order" to set a severely deformed neonate aside to die. Others saved the infant who later died of dehydration and starvation when another physician ordered all treatment(including food and water) withheld . . .

Curtin LL. Conscience and clinical care. Nurs Manage 1993 Aug;24(8):26-8  PMID: 8345933

Leah L. Curtin

  • . . . If the state itself does not presume to order the consciences of Its citizens, how can employers, physicians or hierarchical superiors assume such authority? For those in positions of power, it Is all too easy to stifle the criticisms and consciences of subordinates by a summons to authority - or by an accusation of insubordination. The irony of it is that whether you succeed or fail in your attempts to force obedience through such tactics, you will have Jost your most valuable asset - a inan or woman of Integrity. Within the ethical, professional and legal restraints to which all of us are subject, we can and must create a system that allows for respectful dissent and conscientious objection. . .

Daar JF. A clash at the bedside: patient autonomy v. a physician's professional conscience.  Hastings Law J. 1993 Aug;44(6):1241-89.   PMID: 11652683

Judith F. Daar

  • . . . Judge Belois's holding gave Helga Wanglie the right to demand, and perhaps implicitly the right to receive, intensive medical treatment that at least some physicians felt was medically inappropriate. Thus, if Cruzan is properly pegged as a case about the "right to die," Wanglie surely stands as a contrasting, yet complimentary case about the "right to live." On a factual level, Cruzan stands in contrast to Wanglie in that Cruzan's family sought to withdraw life-sustaining treatment, while the Wanglie family sought to continue treatment in the face of physician objection. Given this contrast, at first blush it may appear that the principles that emerged from the Cruzans' battle for the right to die could not accommodate the dilemma faced by the Wanglies in their quest for continuation of life. But a closer look reveals the complimentary nature of these two situations: In both cases the rights asserted by the patients' families were met with resistance and ultimate opposition from the health care providers caring for the incompetent patients. In the end, both courts looked favorably on the principle of patient self-determination and held that, given a sufficient level of evidence, patients or their surrogates have the right to direct the patients' medical care even in the face of physician opposition. . .

Hogberg U. [A clause of conscience against abortion for students?]Lakartidningen 1993 May 26;90(21):2021-2 (Letter)  [Article in Swedish]  PMID: 8502043

U. Hogberg


Kluge EH. Female circumscision: when medical ethics confronts cultural values. CMAJ 1993; 148 (2)

Eike-Henner Kluge

  • Suppose a physician is asked to perform a procedure that has no recognized medical value and may harm the person who undergoes it. Suppose that the person requesting it is doing so not on her behalf, but for her young daughter. How should the physician respond?

The answer is easy. The doctor will probably say that medical ethics forbids undertaking any procedure that is potentially harmful and has no therapeutic value.

But suppose that the request is so deeply rooted in the cultural background of the woman making the request that the mere suggestion that the procedure is inappropriate would be regarded as a deep insult to her cultural identity. . .

Kymlicka W.  Moral philosophy and public policy: the case of NRTs. Bioethics 1993 Jan;7(1):1-26   PMID: 11654026

W. Kymlicka

  • Abstract:  In this paper, I will express some reservations about the usefulness of moral philosophy for the analysis of public policy issues.... My question is whether taking morality seriously requires taking moral philosophy seriously. This paper focuses on one particular public policy context -- namely, government commissions into new reproductive technologies, such as Britain's Warnock Committee, Australia's Waller and Michael Committees, Canada's Baird Commission, and many others.... Moral philosophers are sometimes asked to participate in these commissions, either as Commissioners, staff, or expert advisers. How can moral philosophers contribute to the analysis of public policy recommendations on NRTs? A survey of the literature suggests that there are two main views on this question, one of which is ambitious, the other more modest. The ambitious view says that moral philosophers should attempt to persuade Commissioners to adopt the right comprehensive moral theory (e.g. adopt a deontological theory, rather than utilitarianism or contractarianism), and then apply this theory to particular policy questions. The more modest view shies away from promoting a particular moral theory, given that the relative merits of different moral theories are a subject of dispute even amongst moral philosophers. Instead, it says that moral philosophers should attempt to ensure that the Commission's arguments are clear and consistent. On this view, philosophers should focus on identifying conceptual confusions or logical inconsistencies within the Commission's arguments without seeking to influence its choice of the underlying theory.

Veatch RM, Spicer CM. Futile care. Physicians should not be allowed to refuse to treat. Health Prog 1993 Dec;74(10):22-7 Comment in: Health Prog. 1994 Jan-Feb;75(1):10-1.  Point.    PMID: 10130086 

R. M. Veatch, C.M. Spicer

  • Abstract: Eighteen years after the era of Karen Ann Quinlan, the debate over futile care has shifted. Now some patients are asking for treatment that care givers believe to be useless. In virtually all cases of so-called futile care, the real disagreement is not over whether a treatment will produce an effect; it is over whether some agreed-on potential effect is of any value. An obvious reason to resist providing care believed to be futile is that is appears to consume scarce resources and therefore burden others. However, for care that affects the dying trajectory but appears to most of us to offer no benefit, the proper course is for society--not clinicians--to cut patients off. Under certain circumstances patients should have the right to receive life-prolonging care from their clinicians, provided it is equitable funded, even it the clinicians believe the care is futile and even if it violates their conscience to provide it. Society is not in a position to override a competent patient who prefers to live even if life prolongation is burdensome. For incompetent patients, if a clinician believes a treatment is actually hurting a patient significantly, he or she may appeal to a court to have it stopped. A society that forces people to die against their will produces more offense than one that forces healthcare providers to provide services that violate their conscience. And medical professionals have a social contract with society to control the use of medical, life-prolonging technologies

Wardle LD. Conscience clauses offer little protection. Most are deficient, and many have been met with hostile judicial interpretations.  Health Prog 1993 Jul-Aug;74(6):79-83 PMID: 10127335 

Lynn D. Wardle

  • Abstract:  Although the federal government and most states have enacted laws protecting healthcare providers' rights to refuse to provide or participate in procedures to which they have moral or religious objections, most such laws are deficient and many have been met with hostile judicial interpretations that have diminished their scope and strength. Deficiencies found in nearly all conscience clause laws include limitations on the specific conduct or procedures protected, restrictive definitions of the healthcare providers covered, and inadequate implementing procedures and remedies. Most conscience clause statutes fail to provide more than token protection for healthcare providers' rights of conscience. Increasing duress on healthcare providers who assert rights of conscience can be expected from three sources. First, some medical schools have considered refusal to participate as a negative factor in the admission process. Second, greater financial pressures on the American healthcare system may cause nonmonetary factors to be sacrificed to the exigencies of the moment. Third, all healthcare reform plans propose an increase in the federal government's role in providing healthcare. At present, the only federal statutory protection for healthcare providers' rights of conscience covers participants in only a few federal programs, is poorly conceived, and is sorely inadequate.

Wardle LD.  A matter of conscience: legal protection for the rights of conscience of healthcare providers. Camb Q Healthc Ethics 1993 Fall;2(4):529-42 PMID: 8149008 Δ

Lynn D. Wardle

  • A growing number of healthcare practices implicate serious moral concerns for growing numbers of healthcare providers. Social, legal, and medical developments, including abortion, contraception, euthanasia, withdrawal of feeding, blood transfusions, organ transplants, and routine autopsies, have put healthcare providers in the vortex of some of society's most controversial moral dilemmas.

Westerholm B, Edgren M. [We are opposing the conscience clause] Lakartidningen 1993 Sep 29;90(39):3302 (Letter)[Article in Swedish]  PMID: 8412423 

B. Westerholm, M. Edgren


Wildes KW. Conscience, referral, and physician assisted suicide. J Med Philos 1993 Jun;18(3):323-8  PMID: 8366322

K.W. Wildes

  • Abstract:  Practices such as physician assisted suicide, even if legal, engender a range of moral conflicts to which many are oblivious. A recent proposal for physician assisted suicide provides an example by calling upon physicians opposed to suicide to refer patients to other, more sympathetic, physicians. However, the proposal does not address the moral concerns of those physicians for whom such referral would be morally objectionable.