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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Alexander JK. Promising, professional obligations, and the refusal to provide service. HEC Forum. 2005 Sep;17(3):178-95. PMID: 16302669

John K. Alexander

  • When we seek professional help (service) we have the expectation that the professionals that we deal with will provide us with competent service. This is especially true when the services we seek are a normal part of the services that the professionals would be called upon to provide in the normal course of their professional lives within the specific practice with which they are associated. However, there have been instances where professionals have refused to provide service in these types of circumstances. In these instances professionals sometimes argue that to provide the requested service would be in violation of their personal moral standards and beliefs and that they ought not to be required to act against what these standards and beliefs require them to do. . .

Appel JM. Judicial diagnosis 'conscience' vs. care how refusal clauses are reshaping the rights revolution. Med Health R I. 2005 Aug;88(8):279-81. PubMed PMID: 16273974.


Barilan YM.  Speciesism as a precondition to justice. Politics and the Life Sciences, 3 March, 2005, Vol. 23, No. 1

Y. Michael Barilan

  • Abstract:  Over and above fairness, the concept of justice presupposes that in any community no one member's wellbeing or life plan is inexorably dependent on the consumption or exploitation of other members. Renunciation of such use of others constitutes moral sociability, without which moral considerability is useless and possibly meaningless. To know if a creature is morally sociable, we must know it in its community; we must know its ecological profile, its species. Justice can be blind to species no more than to circumstance. Speciesism, the recognition of rights on the basis of group membership rather than solely on the basis of moral considerations at the level of the individual creature, embodies this assertion but is often described as a variant of Nazi racism. I consider this description and find it unwarranted, most obviously because Nazi racism extolled the stronger and the abuser and condemned the weaker and the abused, be they species or individuals, humans or animals. To the contrary, I present an argument for speciesism as a precondition to justice.

Beauchamp TL. Conscientious autonomy: what patients do vs. what is done to them. (Letter) Hastings Cent Rep. 2005 Sep-Oct;35(5): 5-6. PubMed PMID:16295255.

Tom L. Beauchamp

  • Rebecca Kukla's engaging article is a theoretically rich and practically wise addition to the literature on autonomy in bioethics. She criticizes what she calls the "one clearly dominant account of autonomy." This "received view" depicts autonomy as self-determination in decision-making through adequate understanding, deliberation, and freedom from controlling interferences;in effect, autonomy is analyzed as informed consent. . . .

Browner CH. Conscientious autonomy: what patients do vs. what is done to them. Hastings Cent Rep. 2005 Sep-Oct;35(5):4-5; author reply 6-7. PubMed PMID: 16295253.

C.H. Browner

Rebecca Kukla's recent article is an ambitious - and vitally needed - attempt to advance current thinking on what patient "autonomy" in medical care would involve if it existed. Her alternative framework derives from the assumption that patients' medical decisions are formed within broader, ongoing social activities, both health-related and not. She's certainly correct to assert that researchers and theorists working on the subject have focused too narrowly on informed consent and that much of what we term"health care" does not involve any decision- making. . .

Castro O, Lombardo FA, Gordeuk VR. The celestial fire of conscience. (Letter) N Engl J Med. 2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180278.

Oswaldo Castro, Frederic A. Lombardo, Victor R. Gordeuk

  • Charo links the "abortion wars" to the refusal by medical personnel to collaborate in certain acts. It is not accurate, however, to assert that medical care or services are being refused. Real medical care and services always respect human life. No one should be forced to collaborate in abortion (even when it is achieved through the prevention of implantation), lethal research on embryos, euthanasia, or assisted suicide. . .

Charo, RA. The Celestial Fire of Conscience - Refusing to Deliver Medical Care.N Engl J Med 2005; 352:2471-2473. [Project response]

R. Alta Charo

  • Apparently heeding George Washington's call to "labor to keep alive in your breast that little spark of celestial fire called conscience," physicians, nurses, and pharmacists are increasingly claiming a right to the autonomy not only to refuse to provide services they find objectionable, but even to refuse to refer patients to another provider and, more recently, to inform them of the existence of legal options for care. . .

Charo, RA. The celestial fire of conscience. N Engl J Med. 2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180276.

R. Alta Charo

  • With regard to Dr. Lee's comment that the proposed Wisconsin legislation does not eliminate a health care provider's duty to provide a referral after refusing to perform a service, I would note that Assembly Bill 207 (passed June 14, 2005, and now pending in the state senate) specifically permits health care providers' refusals to "participate in" services they find personally objectionable, with "participate in" specifically defined in section 2(c) as "to perform; practice; engage in; assist in; recommend; counsel in favor of; make referrals for; prescribe, dispense or administer drugs" (emphasis added).

Coons SJ. Pharmacists' right of conscience: whose autonomy is it, anyway? Clin Ther. 2005 Jun;27(6):924-5. PubMed PMID: 16117992.

Stephen Joel Coons

  • There has been substantial local and national media coverage of issues surrounding a pharmacist's right to refuse to dispense prescription medications that he or she deems objectionable based on personal moral and/or religions beliefs, t.z Much of this attention has been prompted by an increasing number of cases in which pharmacists are refusing to dispense hormonal contraceptives, including, but not limited to, emergency contraception.  In respome, elected representatives at the state and federal levels have been actively engaged in introducing, enacting, or vetoing measures that address this issue from one side or the other; some of these measures are aimed at protecting patients and others are aimed at protecting pharmacists.

Cowley C. A new rejection of moral expertise. Medicine, health care, and philosophy.8 (3):273-9; 2005.

Christopher Cowley

  • Abstract: There seem to be two clearly-defined camps in the debate over the problem of moral expertise. On the one hand are the ''Professionals'', who reject the possibility entirely, usually because of the intractable diversity of ethical beliefs. On the other hand are the ''Ethicists'', who criticise the Professionals for merely stipulating science as the most appropriate paradigm for discussions of expertise. While the subject matter and methodology of good ethical thinking is certainly different from that of good clinical thinking, they argue, this is no reason for rejecting the possibility of a distinctive kind of expertise in ethics, usually based on the idea of good justification. I want to argue that both are incorrect, partly because of the reasons given by one group against the other, but more importantly because both neglect what is most distinctive about ethics: that it is personal in a very specific way, without collapsing into relativism.

Dobbs D. The celestial fire of conscience. N Engl J Med. 2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180277.

David Dobbs

  • Kudos to Charo for reminding us that doctors, hospitals, pharmacists, and pharmacies enjoy monopolies much like those of public utilities  -  and have commensurate service obligations. Imagine if electric utilities refused service to anyone conducting stem-cell research. At least the victims would know that they had been cut off.

Dresser R. Professionals, conformity, and conscience. Hastings Cent Rep. 2005 Nov-Dec;35(6):9-10. PubMed PMID: 16396196.

Rebecca Dresser

  • Laws, regulations, and ethical codes often address conflicts between personal beliefs and workplace demands. Such conflicts are common in the health setting, where work is intimately connected to matters of life and death, privacy, and dignity. In the latest conflict attracting attention, pharmacists have expressed moral beliefs that interfere with women's reproductive health needs. Journalists and others have reported cases of individual pharmacists refusing to fill prescriptions for emergency contraceptives. Because emergency contraception can act to block implantation of a fertilized egg, people who believe in protection of human life after conception find it morally objectionable. . .

Faunce TA. Nurturing personal and professional conscience in an age of corporate globalisation: Bill Viola's "The Passions". Med J Aust. 2005 Dec 5-19;183(11-12):599-601. PubMed PMID: 16336142.


Fenton E, Lomasky L. Dispensing with liberty: conscientious refusal and the "morning-after pill". J Med Philos. 2005 Dec;30(6):579-92. PubMed PMID: 16396786.

Elizabeth Fenton, Loren Lomasky

  • Citing grounds of conscience, pharmacists are increasingly refusing to fill prescriptions for emergency contraception, or the "morningafter pill." Whether correctly or not, these pharmacists believe that emergency contraception either constitutes the destruction of postconception human life, or poses a significant risk of such destruction. We argue that the liberty of conscientious refusal grounds a strong moral claim, one that cannot be defeated solely by consideration of the interests of those seeking medication. We examine, and find lacking, five arguments for requiring pharmacists to fill prescriptions. However, we argue that in their professional context, pharmacists benefit from liberty restrictions on those seeking medication. What would otherwise amount to very strong claims can be defeated if they rest on some prior restriction of the liberty of others. We conclude that the issue of what policy should require pharmacists to do must be settled by way of a theory of second best. Asking "What is second best?" rather than "What is best?" offers a way to navigate the liberty restrictions that may be fixed obstacles to optimality.

Foran JE. The human act and medical practice. Linacre Q. 2005 Feb;72(1):27-30. PubMed PMID: 15856570.


Greenberger MD, Vogelstein R. Public health. Pharmacist refusals: a threat to women's health. Science. 2005 Jun 10;308(5728):1557-8. PubMed PMID: 15947159.

Marcia Greenberger, Rachel Vogelstein

Pharmacist refusals to fill prescriptions for birth control based on personal beliefs have been increasingly reported around the world. In the United States, reports of pharmacist refusals have surfaced in over a dozen states. These refusals have occurred at major drugstore chains like CVS and Walgreens and have affected everyone from rape survivors in search of emergency contraception to married mothers needing birth control pills. Pharmacists who refuse to dispense also often have refused to transfer a woman's prescription to another pharmacist or to refer her to another pharmacy. Other pharmacists have confiscated prescriptions, misled women about availability of drugs, lectured women about morality, or delayed access to drugs until they are no longer effective.

Hurst SA, Hull SC, DuVal G, Danis M. How physicians face ethical difficulties: a qualitative analysis. J Med Ethics. 2005 Jan;31(1):7-14. PubMed PMID: 15634746; PubMed Central PMCID: PMC1734016.

S. A. Hurst, S. C. Hull, G. DuVal, M. Danis

  • Background: Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation.

Objective: To identify strategies used by physicians in dealing with ethical difficulties in their practice.

Design, setting, and participants: National survey of internists, oncologists, and intensive care specialists by computer assisted telephone interviews (n = 344, response rate = 64%). As part of this survey, we asked physicians to tell us about a recent ethical dilemma they had encountered in their medical practice. Transcripts of their open-ended responses were analysed using coding and analytical elements of the grounded theory approach. Main measurements: Strategies and approaches reported by respondents as part of their account of a recent ethical difficulty they had encountered in their practice.

Results: When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients' wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent's integrity and that of the group of decision makers could also compete with each other.

Conclusion: In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process.

James  K. Conflicts of conscience. 45 Washburn L.J. 415 2005-2006

Katherine A. James

  • Introduction: In Texas, a pharmacist refused to fill a rape victim's emergency contraceptive prescription.2 A Wisconsin student encountered a pharmacist who refused to fill her birth control prescription and refused to transfer it to another pharmacist. 3 A pharmacist told a woman in Minnesota seeking birth control to return in a few days to have a different pharmacist assist her.4 These are just a few of the reported incidents of pharmacists refusing to fill contraceptive prescriptions because of the pharmacists' own personal beliefs.5 These beliefs, however, conflict with the customers' right to take the prescribed medication. . .

Kluge EH.  Assisted Suicide & Euthanasia: a Proposal for Restructuring the Criminal Code of Canada.  Humanist Perspectives, vol 38 · no 4 · issue 155 · Winter 2005/06

Eike-Henner Kluge

  • The Criminal Code of Canada prohibits assisted suicide. . .It appears the Parliament has once again decided to consider the issue: this time in the form of Bill C-407 – An Act to amend the Criminal Code (right to die with dignity). The purpose of the Bill is to amend the Criminal Code so as to allow assisted suicide under certain specified conditions. . .If previous experience is anything to go by, Bill C-407 will not be passed into law. The political forces that are arrayed against it are far too well organized, far too powerful and far too vociferous. However, that may not be a bad thing – because the proposed law itself has fundamental flaws and is seriously incomplete. . . the Bill is a partial measure at best. It deals only with assisted suicide, not euthanasia. It would not help those who, although competent, could not perform the final act themselves because they are disabled. . . What follows is an attempt to correct some of these shortcomings. . . .

Kukla R. Conscientious autonomy: displacing decisions in health care. Hastings Cent Rep. 2005 Mar-Apr;35(2):34-44. PubMed PMID: 15957317.

Rebecca Kukla

  • The standard bioethics account is that respecting patient autonomy means ensuring that patients make their own decisions, and that requires that they give informed consent. In fact, respecting autonomy often has more to do with the overall shape and meaning of their health care regimes. Ideally, patients will sometimes take control of their health care but sometimes defer to medical authority. The physician's task is, in part, to inculcate patients into the appropriate good health care regimes

Kukla R. Conscientious autonomy: what patients do vs. what is done to them. (Author reply) Hastings Cent Rep. 2005 Sep-Oct;35(5): 6-7. PubMed PMID:16295255.

Rebecca Kukla

  • My differences with Hilde Lindemann and Carole Browner are terminological rather than substantive. Lindemann rightly suggests that one could reclaim the term "self-determination" and give it a richer, less individualist reading, just as I have tried to do for the term "autonomy." However, in my article I simply stipulated that by self-determination I meant something akin to what she calls self-sufficiency - that is, being an independent, rational source and center of one's own decisions and actions.

Lee M. The celestial fire of conscience. N Engl J Med. 2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16177261.

Matthew Lee

  • With regard to the Perspective article by Charo on conscience clauses, I am disappointed by the treatment of a very serious topic in medicine. The debate over conscience is an important one for both providers and patients. Charo offers distortions of the proposed Wisconsin law, as well as a very biased approach. Even the title frames the discussion in terms of the refusal of care. . .

Lindemann H. Conscientious autonomy: what patients do vs. what is done to them. Hastings Cent Rep. 2005 Sep-Oct;35(5):4; author reply 6-7. PubMed PMID: 16295252.

Hilde Lindemann

  • In "Conscientious Autonomy: Displacing Decisions in Health Care" (HCR, Mar-Apr 2005), Rebecca Kukla argues persuasively that it's a mistake to equate autonomy with the ability to make self-originating, informed, punctate decisions. Often, she points out, we defer to those who can reasonably be assumed to have more authoritative knowledge than we do regarding some particular practice. . .

Manasse HR,  Jr.  Conscientious objection and the pharmacist. Science. 2005 Jun 10;308(5728):1558-9. PubMed PMID: 15947160.

Henri R. Manasse Jr.

  • The recent deluge of media attention about conscientious objection and the role of the pharmacist in helping patients obtain medications that some consider morally objectionable (e.g., the "morning-after pill") presents an opportunity to f ind common ground in what has become a highly charged public debate. State legislators and members of the U.S. Congress have even jumped into the fray with quickly drafted legislation that fails to address the heart of the problem (1).

McLeod C. Conscientious autonomy: what patients do vs. what is done to them (Letter). Hastings Cent Rep. 2005 Sep-Oct;35(5):5; author reply 6-7. PubMed PMID: 16295254.

Carolyn McLeod

  • In her otherwise excellent paper, Rebecca Kukla makes two problematic points about trust. First, she argues that trusting health care providers enough to defer to them does not undermine patient autonomy and can even enhance it, so long as patients conscientiously assess how trustworthy their providers are. And second, she claims that patients need to trust that they are competent to critique their willingness to defer to providers, and also be able to conscientiously evaluate this selftrust. Both points require qualification.

Nadoolman W. The celestial fire of conscience. N Engl J Med. 2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180276.

Wolffe Nadoolman

  • It is curious that pharmacists might refuse to fill a prescription. Must all the prescriptions they fill result from morally acceptable diagnoses? The Health Insurance Portability and Accountability Act of 1996 (HIPAA) does not allow breaches in confidentiality about diagnoses and therapies so that strangers can make individual judgments about whether to cooperate in treating a patient. . .

Nelson JJ. Freedom of Choice for Everyone: The Need for Conscience Clause Legislation for Pharmacists. 3 U. St. Thomas L. J. 139 (2005-2006)

Jessica J. Nelson

  • With ever-increasing advancements in technology comes everincreasing controversy. As society in America continues to legalize medical products and procedures that conflict with many religious traditions, medical professionals frequently have to face the ethical dilemma of whether to perform services that they find morally repugnant. These professionals are often faced with a choice between following their consciences or losing their jobs. In this time of questionable medical advancements, the need for conscience clauses has never been greater. If society is prepared to legalize controversial health care products and procedures, it must also work to protect those who do not agree with them. This paper will address the need for federal and state lawmakers to create conscience clauses in order to protect medical professionals, specifically pharmacists, from being forced to violate their consciences in the workplace.

Report of the task force on issues of conscience. Linacre Q. 2005 May;72(2):133-73. PubMed PMID: 16130238.


Sørlie V, Kihlgren A, Kihlgren M. Meeting ethical challenges in acute nursing care as narrated by registered nurses. Nurs Ethics. 2005 Mar;12(2):133-42. PubMed PMID: 15791783.

Venke Sørlie, Annica Kihlgren and Mona Kihlgren

  • Five registered nurses were interviewed as part of a comprehensive investigation by five researchers into the narratives of five enrolled nurses (study 1, published in Nursing Ethics 2004), five registered nurses (study 2) and 10 patients (study 3) describing their experiences in an acute care ward at one university hospital in Sweden. The project was developed at the Centre for Nursing Science at Örebro University Hospital. The ward in question was opened in 1997 and provides care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The registered nurses were interviewed concerning their experience of being in ethically difficult care situations in their work. Interpretation of the theme 'ethical problems' was left to the interviewees to reflect upon. A phenomenological hermeneutic method (inspired by the French philosopher Paul Ricoeur) was used in all three studies. The most prominent feature revealed was the enormous responsibility present. When discussing their responsibility, their working environment and their own reactions such as stress and conscience, the registered nurses focused on the patients and the possible negative consequences for them, and showed what was at stake for the patients themselves. The nurses demonstrated both directly and indirectly what they consider to be good nursing practices. They therefore demand very high standards of themselves in their interactions with their patients. They create demands on themselves that they believe to be identical to those expected by patients.

Suziedelis A. Requests for inappropriate treatment: can a doctor "just say no"? Health Care Ethics USA. 2005;13(1):E2. PubMed PMID: 16273745.

Ann Suziedelis

  • Executive Summary. This essay examines (1) the underlying philosophical considerations when patients or decision makers request "inappropriate treatment"; (2) questions to consider in determining if the treatment sought would be ineffective, or, in the words of Weijer et al., effective toward a controversial end; and (3) practical ways to resolve such conflicts.

Teliska H.  "Recent Development, Obstacles to Access: How Pharmacist Refusal Clauses Undermine the Basic Health Care Needs of Rural and Low-Income Women." 20 Berkeley J. Gender L. & Just. 229, 231 (2005)

 Holly Teliska

Waller-Wise R.  Conscientious objection: do nurses have the right to refuse to provide care?  AWHONN Lifelines. 2005 Aug-Sep;9(4):283-6 PMID:16218142

Renece Waller-Wise

  • The professional dilemma becomes how to maintain adherence to personal mores and conscience and at the same time carry out the duty to the patient without the appearance of abandonment . . .

West JA. Defining the limits of conscientious objection in health care. APA Newsl Philos Med. 2005 Fall;5(1):25-34. PubMed PMID: 17111540.


Wiesel E. Without conscience. N Engl J Med. 2005 Apr 14;352(15):1511-3. PubMed PMID: 15829530.

Elie Wiesel

  • This is one of those stories that invite fear. Now we know. During the period of the past century that I call Night, medicine was practiced in certain places not to heal but to harm, not to fight off death but to serve it. In the conflict between Good and Evil during the Second World War, the infamous Nazi doctors played a crucial role. They preceded the torturers and assassins in the science of organized cruelty that we call the Holocaust. There is a Talmudic adage, quite disturbing, that applies to them: Tov shebarofim le-gehinom  -  "The best doctors are destined for hell." The Nazi doctors made hell. . .