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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Adams KE. Moral diversity among physicians and conscientious refusal of care in the provision of abortion services. J Am Med Womens Assoc. 2003 Fall;58(4):223-6. Review. PubMed PMID: 14640252.

Karen E. Adams

  • Physicians are independent moral agents whose values, like those of nonphysicians, are shaped by personal experience, religious beliefs, family, and lifetime mentors. Most individuals are free to exercise their moral values in the ways that they see fit within the boundaries of legality. Physicians' moral values take on special significance, however, when considering services patients may request but that contradict that physician's moral beliefs, such as termination of pregnancy. In this article I analyze the competing obligations to self and to patient that a conscientiously objecting physician must consider when his or her personal morality affects his or her relationship with the patient. Despite each physician's freedom to choose his or her mode of practice and which services to provide, a physician with a moral viewpoint that would prevent even counseling on certain options should consider practicing in an area of medicine in which the patient's right to full disclosure of options and informed consent is not compromised by the physician's personal moral stance.

Bartmann P. Physician-assisted suicide and euthanasia: German Protestantism, conscience, and the limits of purely ethical reflection. Christ Bioeth. 2003 Aug-Dec;9(2-3):203-25. PubMed PMID: 15254991.

Peter Bartmann

  • Abstract: In this essay I shall describe and analyse the current debate on physician assisted suicide in contemporary German Protestant church and theology. It will be shown that the Protestant (mainly Lutheran) Church in Germany together with her Roman Catholic sister church has a specific and influential position in the public discussion: The two churches counting the majority of the population in Germany among their members tend to ''organize'' a social and political consensus on end-of-life questions. This cooperation is until now very successful: Speaking with one voice on end-of-life questions, the two churches function as the guardians of a moral consensus which is appreciated even by many non-believers. Behind this joint service to society the lines of the theological debate have to be re-discovered. First it will be argued that a Protestant reading of the joint memoranda has to be based on the concept of individual conscience. The crucial questions are then: Whose conscience has the authority to decide? and: Can physician assisted suicide be desired faithfully? Prominent in the current debate are Ulrich Eibach as a strict defender of the sanctity of life, and on the other side Walter Jens and Hans Küng, who argue for a right to physician assisted suicide under extreme conditions. I shall argue that it will be necessary to go beyond this actual controversy to the works of Gerhard Ebeling and Karl Barth for a clear and instructive account of conscience and a theological analysis of the concepts of life and suicide. On the basis of their considerations, a conscience-related approach to physician assisted suicide is developed.

Berggren I, Severinsson E. Nurse supervisors' actions in relation to their decision-making style and ethical approach to clinical supervision. J Adv Nurs. 2003 Mar;41(6):615-22. PubMed PMID: 12622870.

Ingela Berggren, Elisabeth Severinsson

  • Aim. The aim of the study was to explore the decision-making style and ethical approach of nurse supervisors by focusing on their priorities and interventions in the supervision process.

Background. Clinical supervision promotes ethical awareness and behaviour in the nursing profession.

Methods. A focus group comprised of four clinical nurse supervisors with considerable experience was studied using qualitative hermeneutic content analysis.

Findings. The essence of the nurse supervisors' decision-making style is deliberations and priorities. The nurse supervisors' willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors' ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors' interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings.

Conclusion. Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decisionmaking can strengthen the supervisees' professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.

Briley LD. A physician's professional duty to inform despite personal ethical objections. Curr Surg. 2003 Nov-Dec;60(6):594-5. PMID: 14972197

Laura D. Briley

  • Case: A pregnant woman contracts rubella. The woman is not necessarily opposed to abortion, but she has not talked about it with her physician. The physician is pro-life. When considering this case, it must first be understood that the spread of rubella to the fetus brings with it possible consequences, including congenital and neurological abnormalities as well as miscarriage. Physicians in these cases must decide if it is their duty to inform the patient of options, and should they include abortion, a practice which they may not morally support.

Clark  BR.  When Free Exercise Exemptions Undermine Religious Liberty & the Liberty of Conscience: A Case Study of The Catholic Hospital Conflict.  Oregon Law Review, Vol. 82, p. 625, 2003.  

Brietta R. Clark

  • Abstract:  Police took a woman who was raped to the emergency room of aCatholic hospital for treatment. Doctors examined the woman, butdid not give her any postcoital contraception (the"morning-after pill"), the standard medical treatment for rapevictims used to prevent pregnancy. Even when the patient'smother asked for information about the pill, the physicianrefused to provide any information. The hospital prohibited thephysician from dispensing the pill or giving information aboutit because it violated Catholic doctrine. Consequently, theplaintiff did not obtain the contraception within the 72-hourwindow necessary for it to be effective.

There is a long-standing conflict between patients andreligious hospitals in the area of reproductive health. Thisconflict is getting renewed media attention because of thegrowth of religious hospitals and mergers that eliminatereproductive healthcare for underserved communities. Tosafeguard these services, bills are being proposed that wouldrequire all hospitals to provide such care as a condition ofgovernment funding and other benefits. Catholic hospitals argue that these laws would infringe ontheir First Amendment right to deliver health care in a mannerthat is consistent with their religious beliefs, and that theyshould be exempt from such laws. While the First Amendmentprotects religious liberty, current jurisprudence does notappear to provide religious hospitals protection from theselaws. Under current law, as set forth in Employment Division v.Smith, only laws that intentionally target conduct because ofits religious significance can be challenged. There is noprotection from neutral laws of general applicability thatunintentionally burden religiously motivated conduct. Lawsrequiring all hospitals to provide reproductive health care area prime example of neutral laws of general applicability designed to protect the health and safety of society, but whichunintentionally burden Catholic Hospitals' religious freedom.

This conflict illustrates a fundamental debate about theproper scope of free exercise protection and whether religiouslymotivated conduct should be protected from unintentionalburdens. In this Article, I argue that courts should abandon theSmith test in favor of a more searching intermediate review, butshould not go as far as some states in providing almost absolutefree exercise protection from government laws serving importantinterests. Under this principle, religious freedom should belimited by the government's interest in protecting third partiesfrom harm. The Catholic Hospital conflict provides an importantcase study to understand how this principle would work inpractice. Religious freedom must be balanced against thepotential harm to patients who cannot access medically necessaryreproductive health care and information. Thus, even under thismore protective principle, exemptions should be denied incertain cases, as for example, with informed consent laws orrefusals to perform medically necessary care without making safealternatives. In short, the scenario described at the beginningof this Abstract should not recur. Moreover, granting exemptionsin such cases would undermine, not protect, religious libertybecause the patient is coerced into a making a treatmentdecision based on religious beliefs to which s/he does notsubscribe.

Coulehan J, Williams PC, McCrary SV, Belling C. The best lack all conviction: biomedical ethics, professionalism, and social responsibility. Camb Q Healthc Ethics. 2003 Winter;12(1):21-38. PMID: 12625199

Jack Coulehan, Peter C. Williams, S.  Van McCrary, Catherine Belling

  • Robert Coles' sentiment characterizes well the moral tenor of medical education today. Indeed, medical educators are frequently "seized by spasms of genuine moral awareness," as they try to cope with the massive social and economic problems that face medical schools and teaching hospitals. The perception among educators that we currently fail to adequately teach several core aspects of doctoring, including professional values and behavior, constitutes one such spasm. In this case, the proposed remedy has generated considerable enthusiasm, but whether the "core competencies" curriculum will make a difference, or simply "accommodate to the prevailing rhythms of the world we inhabit," remains to be seen.

Dyer C.  Health authorities cannot force doctors to act against conscience. BMJ. 2003 November 22; 327(7425): 1187

Clare Dyer

  • A health authority has no power to require psychiatrists to act in a way that conflicts with their conscientious professional judgment, the House of Lords ruled last week. . .

Irving,DN. Ph.D Which medical ethics for the 21st century? Linacre Q. 2003 Feb;70(1):46-59. No abstract available. PMID: 14587485


Lichtman J.  Restrictive State Abortion Laws: Today's Most Powerful Conscience Clause.  10 Geo. J. on Poverty L. & Pol'y 345 2003

Julia Lichtman

  • Introduction: In the 1973 landmark case Roe v. Wade, the Supreme Court held that a woman's right to have an abortion is part of the fundamental right to privacy, and, consequently, governmental infringement on that right should be subject to strict judicial scrutiny.2 This groundbreaking opinion contained two exceptions to reproductive freedom that would qualify as compelling state interests, thus allowing states to restrict a woman's right to choose to end her pregnancy: (1) a state could regulate an abortion procedure occurring after the first trimester to protect the woman's health and (2) a state could prohibit abortions after the point of viability (usually twenty-four to twenty-eight weeks), except when the woman's health or life is in danger.3 No sooner had the Court established this fundamental right to choose did state legislatures, the United States Congress, and the Supreme Court itself rally to place restrictions on this liberty interest. These restrictions include parental consent requirements, federal restrictions on the use of public funding to finance abortions, and conscience clauses to protect doctors, medical personnel, and medical entities from any liability for refusing to perform abortions. . . .

Nelson WA, Dark CK. Evaluating claims of conscience. With appropriate guidelines, you can respect staff's beliefs while providing quality care for patients. Healthc Exec. 2003 Mar-Apr;18(2):54-5. PubMed PMID: 12655884.

Nelson, William A;Dark, Cedric K

  • Several physicians at my facility have been citing the conscience clause to opt out of providing certain treatments. How can I be certain that their claims of conscience are sincere and thus warrant honoring?

Place M. Conscience clauses and Catholic health care. Origins. 2003 Sep 11;33(14):225, 227-9. PubMed PMID: 15195641.


Spota K. In good conscience: the legal trend to include prescription contraceptives in employer insurance plans and Catholic charities' "conscience clause" objections.  52 Cath. U. L. Rev. 1081 2002-2003

Kate Spota

  • Imagine a woman running a routine errand in California: she enters her local drug store, hands the pharmacist her prescription for a wellknown drug approved by the Food and Drug Administration (FDA), and then is surprised to learn that her prescription is not covered under her insurance plan. Upon inquiry with her religiously-affiliated employerone that provides health care benefits-she learns that this particular prescription drug was the only one intentionally excluded from her employee prescription plan. The woman must then decide between a thirty-dollar out-of-pocket cost each month or a change in her lifestyle to obviate the need for the drug altogether. How did this situation arise?

Sørlie V, Jansson L, Norberg A. The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses. Scand J Caring Sci. 2003 Sep;17(3): 285-92. PubMed PMID: 12919464.

Venke Sørlie, Lilian Jansson, Astrid Norberg

  • Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.

von Cranach M. The killing of psychiatric patients in Nazi Germany between 1939-1945. Isr J Psychiatry Relat Sci. 2003;40(1):8-18; discussion 19-28. PubMed PMID: 12817666.

M. von Cranach

Between 1939 and 1945 180.000 psychiatric patients were killed in Nazi-Germany. After a brief introduction reflecting the ways of and reasons for addressing this issue today, the details of the so called euthanasia program are presented: The killing of patients by gas in special hospitals between 1939 and 1941 in its first phase and the continuation in the psychiatric hospitals until 1945. In this second phase patients were killed with lethal injections and through the introduction of a hunger diet. The fate of the Jewish patients and forced labourers as well as human experiments are mentioned. Finally some thoughts are presented to answer the question of why this could happen. The giving up of individual responsibility in an authoritarian system leads to the loss of the individual conscience and soul.

Zellick  Private conscience: public duty.  Van Der Zyl Memorial Lecture 2003.  European Judaism Vol. 36 No. 2, Autumn, 2003

Graham Zellick

. . .I want to talk this evening about values and ethics. I do so with some trepidation. I am no theoretician in general or moral philosopher or ethicist in particular. I hope that you aren't either! I shall be speaking partly from practical experience and partly as an academic observer, but considering these matters from a practical or experiential perspective. I am taking it as axiomatic that we have a well-developed value system as individuals and that, as Progressive Jews, we derive that value system in no small measure from our Jewish heritage and the history of our people, tempered by the teaching and thinking that underpin Progressive Judaism. . .