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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Adams MP. Conscience and conflict. Am J Bioeth. 2007 Dec;7(12):28-9; discussion W1-2. PubMed PMID: 18098016.

Marcus P. Adams

  • Lawrence and Curlin claim that those who have recently argued for the separation of medicine and religion "try to achieve this rhetorically" (2007, 10). I believe that there is more than rhetoric that can be offered in this regard. . .

American College of Obstetricians and Gynecologists.  Committee on Ethics. ACOG Committee Opinion No. 385 November 2007: The limits of conscientious refusal in reproductive medicine. Obstet Gynecol. 2007 Nov;110(5):1203-8. PubMed PMID: 17978145.

  • Abstract: Health care providers occasionally may find that providing indicated, even standard. care would present for them a personal moral problem-a conflict of con­science-particularly in the field of reproductive medicine. Although respect for con­science is important. conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient's health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accom­modated only if the primary duty to the patient can be fulfilled. All health care providers must provide accurate and unbiased information so that patients can make informed deci­sions. Where conscience implores physicians to deviate from standard practices, they must provide potential patients with accurate and prior notice of their personal moral com­mitments. Physicians and other health care providers have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. In resource-poor areas, access to safe and legal reproductive services should be maintained. Providers with moral or reli­gious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient's physical or mental health, providers have an obligation to provide medically indicated and requested care.

Barfield R. Conscience is the means by which we engage the moral dimension of medicine. Am J Bioeth. 2007 Dec;7(12):26-7; discussion W1-2. PubMed PMID: 18098015.

Raymond Barfield

  • While the article by Lawrence and Curlin (2007) addresses the issue of how the conscience of caregivers is informed and what role it should play in the complex arena of medical decision-making, there is a foundational definition that should be addressed early in the debate. What is conscience? . . .

Berlinger N. Martin Luther at the bedside. Hastings Cent Rep. 2007 Mar-Apr;37(2):inside back cover. PubMed PMID: 17474344.

Nancy Berlinger

  • The New England Journal of Medicine recently published a study that included data on physicians' personal beliefs about three controversial medical practices: "terminal sedation" (palliative sedation of a dying patient), abortion after failed contraception, and prescribing birth control to an adolescent without parental permission. Of the 1,144 respondents, 17 percent objected to "terminal sedation"; 52 percent objected to the abortion scenario presented; and 42 percent objected to the birth control scenario presented. . .

Blackman, DE. Refusal to Dispense Emergency Contraception In Washington State: An Act of Conscience or Unlawful Sex Discrimination? 14 Mich. J. Gender & L. 59 (2007).

Dana E. Blackman

  • In 1967, Mr. Jangaba Augustine Johnson entered Mr. Wheeler's barbershop seeking a haircut. Mr. Wheeler, licensed barber and owner of the shop, refused service to Mr. Johnson because of his race.  At that time, Mr. Johnson lived in a culture that forced him to travel from shop to shop, or even from town to town, simply to find a barbershop or a lunch counter that would serve him. Nearly forty years later, a woman enters her local pharmacy holding a lawful prescription for emergency contraception. Frightened and nervous, she hands the prescription to the pharmacist, only to be scolded by the person looking down his nose at her: "I will not fill this prescription. I will not help you kill your fetus." The woman is humiliated, and, even worse, is unable to get the drugs she badly needs to prevent an unwanted pregnancy. Living in an isolated area, the nearest alternative pharmacy is far away and the woman lacks transportation. Unless she is able to find a pharmacy that will fill her prescription, she will risk facing an unintended and unwanted pregnancy. . .

Brahmi D, Dehlendorf C, Grumbach K, Joffe C, Gold M, Engel D. A descriptive analysis of abortion training in family medicine residency programs.  Fam Med. 2007 Jun;39(6):399-403 PMID:17549648

Christine Dehlendorf, Kevin Grumbach, Carole Joffe, Dalia Brahmi, Marji Gold, David Engel, MD

  • Abstract: Background and objectives: Access to abortion services in the United States is declining. While family physicians are well suited to provide this care, limited training in abortion occurs in family medicine residency programs. This study was designed to describe the structure of currently available training and the experience of residents participating in these programs.

Methods: E-mail questionnaires were sent to key faculty members and third-year residents in nine programs that have required abortion training. These faculty members and a sample of residents also completed semi-structured interviews.

Results: Residency programs varied in the amount of time dedicated to the procedural aspects of abortion training, ranging from 2 to 8 days, and also in non-procedural aspects of training such as values clarification and didactics. Themes that emerged from interviews with residents included the benefit of training with respect to technical skills and continuity of care. In addition, residents valued discussion of the emotional aspects of abortion care and issues relating to performing abortions after graduation from residency.

Conclusions: While the details of the curricula vary, residents in programs with required abortion training generally felt positively about their experiences and felt that abortion was an appropriate procedure for family physicians to provide. Residents emphasized the importance of both non-procedural and technical aspects of training.

Brody H, Night SS. The pharmacist's personal and professional integrity. Am J Bioeth. 2007 Jun;7(6):16-7. PMID: 17558980

Howard Brody, Susan S. Night

  • The pharmacist's duty to dispense emergency contraception may be approached as a legal, policy, and regulatory issue; as an ethical issue; or as an empirical question. Card (2007) elects to analyze it as a philosophical question having to do with professional ethics, while still (of necessity) grounded in the scientific facts about the nature and mechanism of emergency contraception. This approach leads Card to reject a commonly held "moderate" position - that the pharmacist who conscientiously objects may refuse personally to dispense the medication, but may not refuse to refer the patient to another, willing pharmacist. Card argues instead that the pharmacist is obligated to dispense the emergency contraceptive. . .

Card RF. Conscientious objection and emergency contraception. Am J Bioeth. 2007 Jun;7(6): 8-14. PMID: 17558978

Robert F. Card

  • This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested.

Card RF. Response to commentators on "Conscientious objection and emergency contraception": sex, drugs and the rocky role of levonorgestrel. Am J Bioeth. 2007 Oct;7(10):4-6. PubMed PMID: 17926209.

Robert F. Card

  • I thank the thoughtful commentators on my essay. Their contributions have deepened my grasp of the relevant issues. Unfortunately I cannot discuss each selection in turn, but will instead focus on several commentaries that purport to offer the most serious objections to my argument. Farr Curlin (2007) argues that my paper only addresses "straw-men" (sic) arguments and fails to accurately state the reasons that drive opponents of dispensing emergency contraception (EC). Curlin goes on to present several of the "real" arguments in support of medical providers' right to refuse to dispense EC, yet curiously he does not provide citations to the sources of these arguments. My paper does: for instance, members of Pharmacists for Life International claim that they will not dispense EC since this constitutes doing harm to human life and hence violates the Hippocratic Oath (Stein 2005).Myessay certainly does not purport to examine every conceivable reason, but it does formulate and closely examine the reasons offered by the most vocal proponents of providers' rights to refuse to dispense EC. . .

Conley JJ.  The Conscience of the Pharmacist. Proceedings of the University Faculty for Life, Vol. 17 (2007) 431-437

John J. Conley

  • Abstract: Recent legal efforts to force pharmacists to distribute potentially abortifacient drugs constitute a violation of conscience. This campaign of coercion violates religious freedom, professional deontology, and the right to refuse even material co-operation in acts of grave evil.

Cook ED. Always let your conscience be your guide. Am J Bioeth. 2007 Dec;7(12):17-9; discussion W1-2. PubMed PMID: 18098010.

E. David Cook

  • Jiminy Cricket's advice to Pinocchio was always to let your conscience be your guide (Collodi, Folkland, and Murray 2000). But in calling for physicians "to specify their definitions of the conscience and the reasons for and implications of those definitions" (Lawrence and Curlin 2007, 10), there is a need to define exactly what we mean by the term conscience. Traditionally, conscience covers two main aspects. The first is conscientia, which refers to the inner knowledge of what is right and wrong. The second synderesis - applying your moral principles to actual situations (Fagothey 2000; Gladwin 1977; Wood 2006). Interestingly, the root of the word conscience implies knowledge and agreement with others.

Cook RJ, Erdman JN, Dickens BM.  Achieving transparency in implementing abortion laws. Int J Gynaecol Obstet. (2007) 99, 157-161

  • Abstract:  National and international courts and tribunals are increasingly ruling that although states may aim to deter unlawful abortion by criminal penalties, they bear a parallel duty to inform physicians and patients of when abortion is lawful. The fear is that women are unjustly denied safe medical procedures to which they are legally entitled, because without such information physicians are deterred from involvement. With particular attention to the European Court of Human Rights, the UN Human Rights Committee, the Constitutional Court of Colombia, the Northern Ireland Court of Appeal, and the US Supreme Court, decisions are explained that show the responsibility of states to make rights to legal abortion transparent. Litigants are persuading judges to apply rights to reproductive health and human rights to require states’ explanations of when abortion is lawful, and governments are increasingly inspired to publicize regulations or guidelines on when abortion will attract neither police nor prosecutors’ scrutiny.

Curlin FA. Caution: conscience is the limb on which medical ethics sits. Am J Bioeth. 2007 Jun;7(6):30-2. PMID: 17558988

Farr A. Curlin

  • Card (2007) joins many others (Charo 2005; Savulescu 2006) who are disturbed that clinicians would refuse on moral grounds to provide or help patients obtain emergency contraception (EC) or other legal but controversial clinical practices. Card's essay purports to meet these clinicians in the ring of moral discourse and knock them out fair and square. Yet, further scrutiny suggests the vanquished are only strawmen substitutes for the real opponents, and instead of boxing by the rules, Card has taken off the gloves and thrown 'the kitchen sink' instead. If this approach wins, ethics loses. . .

Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007 Feb 8;356(6):593-600. PubMed PMID: 17287479; PubMed Central PMCID: PMC2867473.

Farr A. Curlin, Ryan E. Lawrence, Marshall H. Chin, John D. Lantos

  • Background: There is a heated debate about whether health professionals may refuse to provide treatments to which they object on moral grounds. It is important to understand how physicians think about their ethical rights and obligations when such conflicts emerge in clinical practice.

Methods : We conducted a cross-sectional survey of a stratified, random sample of 2000 practicing U.S. physicians from all specialties by mail. The primary criterion variables were physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for religious or moral reasons. These procedures included administering terminal sedation in dying patients, providing abortion for failed contraception, and prescribing birth control to adolescents without parental approval.

Results: A total of 1144 of 1820 physicians (63%) responded to our survey. On the basis of our results, we estimate that most physicians believe that it is ethically permissible for doctors to explain their moral objections to patients (63%). Most also believe that physicians are obligated to present all options (86%) and to refer the patient to another clinician who does not object to the requested procedure (71%). Physicians who were male, those who were religious, and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds (multivariate odds ratios, 0.3 to 0.5).

Conclusions: Many physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures. Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests.

de Melo-Martin I. Should professional associations sanction conscientious refusals? Am J Bioeth. 2007 Jun;7(6):23-4. PMID: 17558984

Inmaculada de Melo-Martin

  • As Robert Card (2007) shows, the refusal of some pharmacists to fill prescriptions for emergency contraception on conscientious grounds has resulted in significant public debate. Indeed, several state legislatures now protect the right of pharmacists to refuse to fill legally valid prescriptions because of personal beliefs (Guttmacher Institute 2007). Although much of the discussion has focused on trying to find a moderate position that would balance the right of pharmacists to not participate in activities that they find objectionable with the needs of patients, little attention has been given to whether such middle ground is as unproblematic as it seems. Card's work attempts to fill this gap by showing that such a moderate position is in fact questionable.

Dyer C.  BMA claims GMC guidance on conscience goes too far. BMJ. 2007 October 6; 335(7622): 688.

Clare Dyer

The BMA has clashed with the UK General Medical Council about draft guidance from the GMC for doctors who object to providing certain medical services on the ground that they conflict with their personal beliefs. In its response to the draft of Personal Beliefs and Medical Practice the BMA argues that the guidance goes beyond doctors' widely accepted right to opt out of certain procedures that involve matters of life and death, such as abortion, contraceptive services, and the withdrawal of life prolonging treatment. The association claims it could confuse patients and give doctors a licence to discriminate. . .

Emerson CI, Daar AS. Defining conscience and acting conscientiously. Am J Bioeth. 2007 Dec;7(12):19-21; discussion W1-2. PubMed PMID: 18098011.

Claudia I. Emerson, Abdallah S. Daar

  • Lawrence and Curlin (2007) claim that disputes around what significance and role the conscience should take in the practice of medicine can be better understood by recognizing the definition of conscience that is presupposed by disputants. They succeed in their objective to "draw attention to and promote discussion about the plurality of ways that the conscience is described, and the differing roles the conscience is said to have" (2007, 10), but it is unclear how much this can actually contribute to mitigating the underlying conflict, which ultimately centers on whether a physician is ever justified in invoking conscientious objection at the expense of those she is meant to serve. Specifying

Evans EW. Conscientious objection: a pharmacist's right or professional negligence? Am J Health Syst Pharm. 2007 Jan 15;64(2):139-41. PubMed PMID: 17215462.

Emily W. Evans

  • In Texas, three pharmacists are fired for refusing to fill a rape victim's prescription for emergency contraception because it "violated [their] morals." A Wisconsin pharmacist refuses to fill, or transfer out, a similar prescription and is put on trial for violating the state's regulation and licensing department's standards of care. He stated that he "did not want to commit a sin." A group of Illinois pharmacists sue their employer for religious discrimination after they were each disciplined for refusing to fill prescriptions for emergency contraception. . .

Girard NJ. Surgical conscience: still pertinent. AORN J. 2007 Jul;86(1):13-4. PubMed PMID: 17621442.

Nancy J. Girard

  • Somewhere in their curricula, schools of nursing and institutions that teach perioperative nursing usually address the concept of "surgical conscience." Course competency statements and learning outcomes often include criteria mandating that the student will demonstrate surgical conscience as evidenced by consistently exhibiting ethical behavior, promoting patient safety, and doing the right thing even when no external monitors are present (although it is unclear how it could be determined that surgical conscience was being exercised without someone watching). The importance of listening to one's surgical conscience may or may not be drilled into students, depending on the institution and the instructor.

Glasberg AL, Eriksson S, Norberg A. Burnout and 'stress of conscience' among healthcare personnel. J Adv Nurs. 2007 Feb;57(4):392-403. PubMed PMID: 17291203.

A. L. Glasberg, S. Eriksson, A. Norberg

  • Abstract:  Aim. This paper reports a study examining factors that may contribute to burnout among healthcare personnel.

Background. The impact on burnout of factors such as workload and interpersonal conflicts is well-documented. However, although health care is a moral endeavour, little is known about the impact of moral strain. Interviews reveal that healthcare personnel experience a troubled conscience when they feel that they cannot provide the good care that they wish – and believe it is their duty – to give.

Methods. In this cross-sectional study, conducted in 2003, a sample of 423 healthcare personnel in Sweden completed a battery of questionnaires comprising the Maslach Burnout Inventory, Perception of Conscience Questionnaire, Stress of Conscience Questionnaire, Social Interactions Scale, Resilience Scale and a personal/work demographic form.

Results. Regression analysis resulted in a model that explained approximately 59% of the total variation in emotional exhaustion. Factors associated with emotional exhaustion were 'having to deaden one's conscience', and 'stress of conscience' from lacking the time to provide the care needed, work being so demanding that it influences one's home life, and not being able to live up to others' expectations. Several additional variables were associated with emotional exhaustion. Factors contributing to depersonalization were 'having to deaden one's conscience', 'stress of conscience' from not being able to live up to others' expectations and from having to lower one's aspirations to provide good care, deficient social support from co-workers, and being a physician; however, the percentage of variation explained was smaller (30%).

Conclusion. Being attentive to our own and others' feelings of troubled conscience is important in preventing burnout in health care, and staff need opportunities to reflect on their troubled conscience. Further research is needed into how a troubled conscience can be eased, particularly focusing on the working environment.

Glenn LM, Boyce J.  The Tao of Conscience: Conflict and Resolution. Am J Bioeth. 2007 Dec;7(12): 33-34

Linda MacDonald Glenn, Jeanann Boyce

  • Lawrence and Curlin (2007) outline the two traditional paths that help define 'conscience': the fundamentalist approach and the secular approach. These paths fall into the classic dualistic notion that the world is made up of divisions between the self and the other, mind and body, consciousness and form, good and bad, here and there, past and future (Wilber 2001, 69). The difficulty with this notion is that it suggests that decisions are being made in a moral vacuum: it sets up an "us versus them" adversarial scenario, rather than establishing a basis for trust, the foundation of the physician - patient relationship.

Haddad A. A matter of conscience. RN. 2007 Apr;70(4):24. PubMed PMID: 17479689.

Amy Haddad

  • May I refuse to care for patients with AIDS by raising a conscientious objection? As long as a patient isn't abandoned, you can refuse to perform an action based on conscience. But in the case of a patient who is HIV-positive or has AIDS, it's hard to imagine how your objection could be based on this reasoning. . .

Hardt JJ. The necessity of conscience and the unspoken ends of medicine. Am J Bioeth. 2007 Jun;7(6):18-9. PubMed PMID: 17558981.

John J. Hardt

  • I am a proponent of the validity of conscience as a moral determinant of action in the clinical encounter. But there is much with which I agree in Professor Card's article (2007). The use of pharmacists and physicians as gatekeepers is a problem that needs to be resolved if conscience is going to be protected and patient access to legal medications is going to be assured. The moral necessity of allowing one to follow the dictates of conscience and the social good of making legally-sanctioned medications readily available must jointly be preserved.

Hardt JJ.  Conscience and the ends of medicine.  Paper delivered to the President's Council on Bioethics, November 8, 2007.

John J. Hardt

  • . . .This morning, I hope to build upon Dr. Pellegrino's closing comments from your meeting of September 6 in which he recognized something of an identity crisis in medicine today. He suggested that we ought to attend to the current confusion concerning the profession's understanding of its own relationship to society, a confusion that Dr. Pellegrino suggested might be resolved, at least in part, by what he called a "reprofessionalization," a kind of reestablishment of the moral foundations of medicine that would undergird the traits that characterize "professionalism" - as he described them: competence, fidelity, and trust - with a normative moral vision of the profession itself.

I think that the recent debates concerning conscience in the clinical encounter are an important expression of this confusion about medicine's relationship to society noted by Dr. Pellegrino. I say this because I wonder if the question of conscience's role is, at its core, a question about how medicine, individually embodied in the physician, relates to society, individually embodied in the patient. . .

Harrington MM.  The Ever-Expanding Health Care Conscience Clause: The Quest for Immunity in the Struggle Between Professional Duties and Moral Beliefs. 34 Fla. St. U. L. Rev. 779, 816 n.237 (2007)

  • Introduction:  During the past few years, the debate over whether health care professionals should be required to provide services that conflict with their personal beliefs has focused primarily on pharmacists refusing to fill prescriptions.1 According to one media account, during a sixmonth period in 2004 there were approximately 180 reports of pharmacists refusing to dispense routine or emergency oral contraceptives. 2 This controversy, however, extends beyond the pharmacy into every facet of the heath care system. . .

Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience in relation to stress of conscience. Nurs Ethics. 2007 May;14(3):329-43. PubMed PMID: 17459817.

Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin

  • Every day situations arising in health care contain ethical issues influencing care providers' conscience. How and to what extent conscience is influenced may differ according to how conscience is perceived. This study aimed to explore the relationship between perceptions of conscience and stress of conscience among care providers working in municipal housing for elderly people. A total of 166 care providers were approached, of which 146 (50 registered nurses and 96 nurses' aides/enrolled nurses) completed a questionnaire containing the Perceptions of Conscience Questionnaire and the Stress of Conscience Questionnaire. A multivariate canonical correlation analysis was conducted. The first two functions emerging from the analysis themselves explained a noteworthy amount of the shared variance (25.6% and 17.8%). These two dimensions of the relationship were interpreted either as having to deaden one's conscience relating to external demands in order to be able to collaborate with coworkers, or as having to deaden one's conscience relating to internal demands in order to uphold one's identity as a 'good' health care professional.

Kurjak A, Carrera JM, McCullough LB, Chervenak FA. Scientific and religious controversies about the beginning of human life: the relevance of the ethical concept of the fetus as a patient. J Perinat Med. 2007;35(5):376-83. PubMed PMID: 17624932.

Asim Kurjak, Jose Maria Carrera, Laurence B. McCullough, Frank A. Chervenak

  • Abstract:  In this paper we show that the question, "When does human life begin?", is not one question, but three. The first question is, "When does human biological life begin?", and is a scientific question. A brief review of embryology is provided to answer this question. The second question is, "When do obligations to protect human life begin?", and is a question of general theological and philosophical ethics. A brief review of major world religions and philosophy is provided to answer this question but has no settled answer and therefore involves irresolvable controversy. The third question is, "How should physicians respond to disagreement about when obligations to protect human life begin?" and is a question for professional medical ethics. A review of the ethical concept of the fetus as a patient is provided to answer this question. Physicians should manage the irresolvable controversy surrounding the second question by appealing to the ethical concept of the fetus as a patient. It is phi losophically sound, respectful of all religious traditions and the personal convictions of patients and physicians alike, and clinically applicable.

Ladd RE. Some reflections on conscience. Am J Bioeth. 2007 Dec;7(12):32-3; discussion W1-2. PubMed PMID: 18098018.

Rosalind Ekman Ladd

  • When we say to physicians, "Don't impose your values on your patients," we are articulating a basic principle integral to a pluralistic society. And for those who subscribe to this principle, it does not really matter how the values were formed. Thus, while it is interesting and doubtless true that the values underlying individual conscience may have their source for some people in religion and for others in a secular, rationalistic tradition, it is not at all clear that, as Lawrence and Curlin (2007) claim, recognizing the clash of definitions that arises from the different sources of conscience will either advance a more robust conversation about the reasons and ends of medicine or help resolve any of the controversial problems in bioethics. . .

LaFollette H. The physician's conscience. Am J Bioeth. 2007 Dec;7(12):15-7; discussion W1-2. PubMed PMID: 18098009.

Hugh LaFollette

  • Lawrence and Curlin claim that we fail to resolve issues about medical professionals' claims to rights of conscience because we do not attend appropriately "to the possibility that disputants are operating with contrasting definitions" (2007, 10). If we appreciated these differences, then "new light will be cast on current controversies and new strategies will emerge for negotiating accommodations between those who disagree" (2007, 10) I am not so sure. I suspect that most people who are familiar with these issues understand all too well that disputants operate with different views (not different definitions) of conscience.

LaFollette E, LaFollette H. Private conscience, public acts: Does private conscience trump professional duty? J Med Ethics. 2007 May;33(5):249-54. PubMed PMID: 17470498; PubMed Central PMCID: PMC2598118.

Eva LaFollette, Hugh LaFollette

  • In the US, ambulance drivers have refused to transport patients for abortions, a fertility clinic refused to assist a gay woman and a pharmacist refused to give the morning-after pill to a rape victim. In the UK, the Catholic Church claims to be exempt from laws forbidding adoption agencies from discriminating against homosexuals. A growing number of pro fessionals now assert a right of conscience, a right to refuse to do anything they deem immoral, and to do so with impunity. Such claims emerged 40 years ago when some doctors and nurses claimed a right to refuse to perform (or assist in performing) an abortion. . .

Lawrence RE, Curlin FA. Clash of definitions: controversies about conscience in medicine. Am J Bioeth. 2007 Dec;7(12):10-4. PubMed PMID: 18098008.

Ryan E. Lawrence, Farr A. Curlin

  • What role should the physician's conscience play in the practice of medicine? Much controversy has surrounded the question, yet little attention has been paid to the possibility that disputants are operating with contrasting definitions of the conscience. To illustrate this divergence, we contrast definitions stemming from Abrahamic religions and those stemming from secular moral tradition. Clear differences emerge regarding what the term conscience conveys, how the conscience should be informed, and what the consequences are for violating one's conscience. Importantly, these basic disagreements underlie current controversies regarding the role of the clinician's conscience in the practice of medicine. Consequently participants in ongoing debates would do well to specify their definitions of the conscience and the reasons for and implications of those definitions. This specification would allow participants to advance a more philosophically and theologically robust conversation about the means and ends of medicine. . .

Lindsay RA. When to grant conscientious objector status. Am J Bioeth. 2007 Jun;7(6):25-6. PubMed PMID: 17558985.

Ronald A. Lindsay

Robert Card (2007) provides a thoughtful and timely analysis of an important public policy issue. Unfortunately, the significance and force of his analysis is considerably limited by his decision to forego discussion of the legal and regulatory framework for conscientious objector status and focus almost exclusively "on professional ethical obligations" (2007, 8). The primary concern of persons seeking emergency contraception (EC) is not whether physicians or pharmacists might disapprove of a fellow professional who refuses to prescribe or dispense EC. These persons want EC and they want some pressure applied to those who would deny them EC that is more forceful and effective than moral censure.

Lindström M.  Gynekologer och barnmorskor inom svensk abortvård - åsikter, erfarenheter och upplevelser. [English title; Gynecologists and midwives about Swedish abortion care- views, experiences and perceptions] Umeå University, Faculty of Medicine, Department of Clinical Science, Obstetrics and Gynecology, 2007. Umeå University Press, september 2007:2003581 Serie nr 1121 ISBN 0346-6612 ISSN 978-91-7264-404-5

Meta Lindström

  • Aim: To investigate gynecologists' and midwives' views and experiences regarding work in abortion care in Sweden.

Methods: Questionnaire to gynecologists (n=269) and midwives (n=258) comprising 48 questions, response 85%. The quantitative studies (articles I-III) were supplemented by a qualitative study (article IV), consisting of focus-group interviews with gynecologists and midwives/nurses.

Results: From the questionnaire studies it was apparent that all the gynecologists had worked in abortion care, whilst not all midwives had done so. The male gynecologists were older than both their female colleagues and the midwives; they had most years of experience but were now working least with abortion patients. Both groups considered it absolutely right, that Sweden have legal abortion and that the law was being followed. Most thought that women should be allowed to have an abortion even after they had felt fetal movements. The midwives were generally somewhat more restrictive than the gynecologists. Half of all thought that the work with abortion patients brought something positive with it. Those having worked longest and most extensively, especially during the previous year were most liberal. Both groups felt that there was a difference between working with surgical and late abortions compared with medical abortions. One in four had had misgivings when involved in surgical and medical abortions, and one in two with abortions after the 18th week. All were positive about the transition to medical abortions, and roughly two thirds of the midwives thought that the primary care sector should be able to take care of these, whereas less than half of the gynecologists thought this. The majority considered it important to receive further and continuing professional development and ongoing guidance. From the focus-group interviews it was clear that the experiences of the gynecologists were largely connected with the technical development of abortion methods and those of the midwives/nurses with improved pain relief. The work was sometimes described in paradoxical terms and was occasionally experienced as frustrating, especially in connection with repeat abortions. Neither of the two groups, however, had had any doubts about participating in abortion. The gynecologists described how women now expected to get an abortion, whereas previously they had asked for one. The midwife/nurse group maintained that the meetings with the women had become considerably more frequent. The interaction between the two professional groups was marked by great trust in each other's professional competence.

Conclusions: Gynecologists and midwives working in abortion care support Swedish abortion legislation and have no doubts about participating in abortions, despite the fact that they have frequently experienced complex and difficult work situations. The character of the work is experienced as contradictory and frustrating, but also as challenging and rewarding. The awareness that the two professional groups have of the importance of continuing professional development and ongoing guidance should be acted on. Furthermore, their collective views and experiences should be made use of, so that abortion care can be developed, not only in order to promote women's health, but also to improve the work environment for the abortion staff.

Loeben G, Chui MA. Conscientious objection: does the zero-probability argument work? Am J Bioeth. 2007 Jun;7(6):28-30. PMID: 17558987.

Greg Loeben, Michelle A. Chui

  • Speaking generally, we find a great deal of the argumentation in Card's (2007) article to be incomplete. For example, although Card claims to have argued that referral is not an ethically acceptable alternative to dispensing emergency contraception (EC), it seems far more accurate to say, in addition to Carson Strong (2007), that the author has in fact only shown that the option of referral may not be ethically acceptable to some conscientious objectors. . .

McGuiness S.  Review of Helen Watt (ed.) Cooperation, Complicity & Conscience, The Linacre Centre, London, 2005. Medical Law Review, 15, Summer 2007, pp. 262–277 doi:10.1093/medlaw/fwm002

Sheelagh McGuinness

  • From the outset, the concerns of this book are clearly Catholic concerns. It deals with the problems of conscience Catholics may have when carrying out their duties in everyday life. Whether it can bridge the gap in order to appeal to a wider audience is questionable, but there is certainly a lot to consider in this collection. Consisting of 15 thought-provoking essays, it is nothing if not comprehensive. These essays were first presented at the 2003 International Conference of the Linacre Centre for Healthcare Ethics on Cooperation in Evil and Conscientious Objection. The arguments put forward in this book offer interesting and often sophisticated insights into the many facets these problems can take. At times, however, it may appear to the non-Catholic that these problems are more apparent/created than real. . .

Meyers C, Woods RD. Conscientious objection? Yes, but make sure it is genuine. Am J Bioeth. 2007 Jun;7(6):19-20. PubMed PMID: 17558982.

Christopher Meyers, Robert D. Woods

  • Robert Card has written an important and careful paper (2007). It is important because this is clearly a pressing issue with powerful politics attached. One need only do a web search for "pharmacists and conscience" to see the kind of heated rhetoric driving the conversation, which is why Card's careful and discerning examination is of such value. Heconvincingly analyzes the issues at stake, includingsome of the key but subtle points. While we might quibble with a few of his specific lines of reasoning (for example, we think there is an important difference between conscientious objection and civil disobedience), we want instead to discuss Card's key suggestion toward the end of the essay.

Night SS. Negotiating the tension between two integrities: a richer perspective on conscience. Am J Bioeth. 2007 Dec;7(12):24-6; discussion W1-2. PubMed PMID: 18098014.

Susan S. Night

  • Conscientious objection by healthcare professionals, in particular physicians, is not necessarily a recent phenomenon but of late there have been efforts to vastly expand this concept in the clinical setting. It is fairly well settled in law and policy that physicians have a moral duty to their own personal integrity to refuse to participate in abortion procedures if doing so would compromise a strongly held religious or philosophical belief. However, other areas where physicians may also express an objection, such as a refusal to prescribe needed medication because it is derived from stem cells or provide fertility services to gay persons, remain controversial. . .

Neale A. Who really wants health care justice? Health Prog. 2007 Jan-Feb;88(1):40-3, 69. PubMed PMID: 17274577.

Ann Neale

  • Abstract:  U.S. health care is at a crossroads. It faces many challenges--the most evident being unsustainable cost increases and diminishing access. For decades, attempts at reform have been unsuccessful. One reason our traditional approaches have not worked is that we who serve the ministry have not brought to those efforts sufficient reflection concerning the deeper, values-level attitudes concerning reform. Instead, the reform movement has concentrated on promoting particular policy solutions. Ultimately, of course, we must agree on a delivery and financing system if we are to redress the situation. But first we must recognize that U.S. health care's fundamental challenge is moral and social in nature. Stakeholders will not let go of the status quo until a critical mass of people becomes convinced that there is a serious moral and social imperative to do so. Social change of this magnitude is not simply a matter of comprehensive new policy. To be effective, it must be accompanied by sustained individual and public conscience work that grounds a significant social movement comprising a critical mass of each of those stakeholders. Several principles from the Catholic tradition--the common good, solidarity, and stewardship--are particularly relevant to the individual and public conscience work necessary in the health care reform movement. Health care professionals and organizations are simultaneously part of the solution and part of the problem. By keeping this interior dialogue alive, in ourselves and in our work communities, we are much more likely to get at the root causes of our unjust health system and to contribute to the larger social movement that brings about more health care justice. This article contains a "conscience work exercise" that will help individuals and organizations examine and identify the values, attitudes, and dispositions that contribute to health care justice and those that keep us mired in the status quo.

Olsen D. Nursing and other health care disciplines have a longstanding tradition of conscientious objection. Nurs Ethics. 2007 May;14(3):277-9. PubMed PMID: 17459812.

Douglas Olsen

  • Nursing and other health care disciplines have a longstanding tradition of conscientious objection. Clinicians can refuse to participate when they believe that it would be morally wrong to give the treatment requested by a patient. In the USA, the right to refuse participation in certain forms of treatment based on religious or conscientious objections is enshrined in the laws of many states and in the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards.1 Until recently this standard was uncontroversial and was considered an essential way for clinicians to preserve their own moral autonomy. Two recent conscientious objection cases show the need for reconsideration of this standard: the first was the refusal by some pharmacists to dispense birth control agents, and the second the refusal of Catholic hospitals receiving public funds to dispense morning-after birth control prescriptions to rape victims.

Orr RD. The role of moral complicity in issues of conscience. Am J Bioeth. 2007 Dec;7(12):23-4; discussion W1-2. PubMed PMID: 18098013.

Robert D. Orr

  • Lawrence and Curlin (2007) have addressed the question of what role a physician's conscience should play in his or her practice of medicine by drawing some insightful distinctions in definitions of conscience. They have focused on different understandings of conscience in religious and secular traditions. In addressing the question of the consequences of not following one's conscience, the authors distinguish between divine retribution for the religious physician and temporal consequences for physicians applying secular reasoning (Lawrence and Curlin 2007). They do not, however, go beyond this question to address the issue of moral complicity. . .

Pinera B. [Medicine between two sets of values: the Biblical Ethics and human or modern ethics]. Rev Med Chil. 2007 Jun;135(6):800-5. Epub 2007 Aug 22. Spanish. PubMed PMID: 17728909.

Bernardino Pinera

  • In this article, the author - a Bishop of the Catholic Church- discusses the similarities and differences between two sets of ethical values that may guide the behaviour of medical professionals towards their patients and society. One set derives from Biblical principles contained in the Old and New Testaments, mainly represented by the Ten Commandments and Christ's Prayer from the Mountain. These principles are shared by all Christian nominations and by the Jewish and Muslim religions. The second one, although intrinsically agnostic, is also focused in the human individual and the human society. Both streams obey a "natural morality" common to all humans: every individual should respect each one's conscience, should avoid doing to others what each one would not like to receive, to do not lie, kill or rob, to obey the rules of family and society. The Biblical Ethics stresses the value of responsibility in human behaviour while Modern Ethics sets the point in authenticity. In spite of their differences, the sharing of crucial points and end goals should inspire medical professionals regardless their religious beliefs to follow a common set of ethical values and to remain united in pursuing it.

Rudd G. Healthcare without conscience--unconscionable! Ann Pharmacother. 2007 Nov;41(11):1903-5. Epub 2007 Oct 16. PubMed PMID: 17940123.

Gene Rudd

  • The American public and government response to media reports of pharmacists refusing to fill prescriptions due to moral objections could fundamentally alter health care. Denying one group of citizens the right to act on their conscience puts each citizen in jeopardy of losing First Amendment rights. Denying healthcare professionals the right to act on their conscience puts patients at risk of being cared for by those who are less than professional, those whose character attributes essential to quality care are compromised. We can define better solutions for access to legal prescriptions and therapies without demanding that healthcare professionals become complicit in activities they deem immoral.

Savulescu J. The proper place of values in the delivery of medicine. Am J Bioeth. 2007 Dec;7(12):21-2; discussion W1-2. PubMed PMID: 18098012.

Julian Savulescu

  • There has been much recent debate about what role conscience should play in the delivery of medicine. Lawrence and Curlin argue that disputants in this debate "are operating with contrasting definitions of the conscience" (2007, 10). They go on to argue that "differences emerge regarding what the conscience conveys, how the conscience should be informed, and what the consequences are for violating one's conscience" (10) and that this can account for some of the dispute. I disagree that it is differences in conceptions of conscience that can account for this dispute. I will locate the cause of this dispute not in different concepts of conscience but in different understandings of the role of values in the delivery of medicine. . .

Simpson T. "If your hand causes you to sin . . .": Florida's chemical castration statute misses the mark. Florida State University Law Review, Vol. 34:1221

Tanya Simpson

Introduction:  On May 4, 2005, convicted Texas child molester Larry Don McQuay was released from prison. Again. McQuay, who had been a school bus driver in San Antonio, Texas, had been initially sentenced to eight years in prison for molesting a six-year-old boy in 1989. McQuay begged the state of Texas to surgically castrate him so that he would not repeat his crimes, which he admitted included molesting over 200 children. McQuay stated that when he looks at a child, " 'I see a sex object . . . . I hate the things that I do. I'm just scaredthat it's going to happen. That's why I want to get the surgery.' " His request was denied. McQuay's letters from prison prompted the citizens' organization, Justice for All, to help him raise the funds to obtain the surgery privately. Although the organization was successful in raising the funds, they could find no physician who was willing to perform the surgery. . .

Smajdor A.  The Moral Imperative for Ectogenesis. Cambridge Quarterly of Healthcare Ethics (2007), 16, 336–345.

Anna Smajdor

  • The United Kingdom, like many other affluent Western societies, is apparently in the grip of declining fertility. The resultant strain on the economy caused by an aging population is being exacerbated by what has been characterized as the selfishness of women who delay reproduction in their efforts to secure financial and social status before getting around to starting a family. Such women may only begin to think about having children in their mid-30s, an age that, according to research, is a predictor of "serious morbidity" in pregnancy and childbirth. And for many of those who try to start families when in their 30s, their fertility may have declined so that they may not be able to have children at all or may need to resort to reproductive therapies to do so. . .

Stotland NL, Ross LF, Clayton EW, Mishtal JZ, Chavkin W, Zarate V, O'Connell P, Mistrot J, Parsons KC,  Curlin FA, Lawrence RE, Chin MH, Lantos JD.  Religion, conscience, and controversial clinical practices. (Letters and authors' reply) N Engl J Med. 2007 May 3;356(18):1889-92. PubMed PMID: 17476021.

Nada Stotland, Lainie F. Ross, Ellen W. Clayton, Joanna Z. Mishtal, Wendy Chavkin, Victor Zarate, Patrick O'Connell, Jacques Mistrot, Kenneth C. Parsons, Farr A. Curlin, Ryan E. Lawrence, Marshall H. Chin, John D. Lantos

  • Stotland: The policy of the American Medical Association states, "The patient has the right to receive information from physicians and to discuss the benefits, risks, and costs of appropriate treatment alternatives." . . .

Ross, Clayton:  More disturbing than the data described by Curlin et al. is the authors' conclusion: "Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests." . . .

Mishtal, Chavkin:  Curlin et al. provide documentation that patients may not receive information about medical options because of the religious beliefs of their physicians. The history of Poland shows how a conscience clause can lead to the systemic deprivation of services. . .

Zarate:  The findings of Curlin et al. are timely for Chile, where there is a fierce controversy about whether the morning-after pill should be prescribed for girls as young as 14 years of age without their parents' consent. . .

O'Connell, Mistrot: Curlin et al. note the association between physicians' religiosity and their decreased willingness to refer patients for interventions that the physicians find morally objectionable, and the authors place this association within the context of paternalism versus patient autonomy. . .

Parsons:  Until recently, I was an attending physician for patients with spinal cord injury during their initial rehabilitation. Many of those patients were on life support and despaired of going on with life, voicing a request for termination of their lives. Decisions based on patient autonomy alone would have had us doing so. . .

Curlin, Lawrence, Chin, Lantos (authors): If a judgment of conscience were merely a statement of personal preference or an expression of prejudice, the claims of Dr. Stotland and Drs. Ross and Clayton would be justified.  But anyone who has been hounded by a sense that he or she has acted wrongly knows that is not how the conscience works. . .

Strong C. Conscientious objection the morning after. Am J Bioeth. 2007 Jun;7(6):32-4. PubMed PMID: 17558989.

Carson Strong

  • Robert F. Card (2007) argues that pharmacists who conscientiously object to filling prescriptions for emergency contraception (EC) should, despite their personal views, always fill them. His view, according to which a pharmacist's conscientious objection concerning EC should always yield to the patient's interests, is at one extreme of a spectrumof possible views. The opposite extreme, that a pharmacist's right to conscientious objection concerning EC is never overridden by patient interests, has been advocated by others (Stein 2005). A middle-ground view might be something like this: when conscientious objection can occur without an undue risk of harm to the patient, it is permissible; when it cannot be performed without such risk, the pharmacist's duty to promote the interests of the patient overrides the right to conscientious objection. This wording of the middle ground view leaves open the definition of an undue risk and suggests that a variety of views is possible. I believe that both of the extreme views are mistaken, but here I shall argue only that the defense Card puts forward for his view is defeated by several serious objections. . .

Tomkowiak S.  Reconciling principles and prescriptions: Do pharmacist refusal clauses strike the appropriate balance between pharmacists' and patients' rights? University of Illinois Law Review Vol. 2007 No. 4, 1329-1360

  • Conclusion: When a woman and her physician decide that a prescription for con-traception is in her best health interests, legal, professional, and ethical obligations should prevent a pharmacist from being able to effectively override that determination. The right of a pharmacist to abide by her moral or religious principles when faced with a prescription that goes against those principles is an important right to protect. However, this right should never be allowed to infringe on a patient’s right to access birth control, an equally important right that has significant implications for the majority of American women’s reproductive health. Pharmacist refusal clauses acknowledge pharmacists’ right to refuse at the expense of women’s right to access contraceptives, inappropriately reconciling these rights. Griswold v. Connecticut may be forty years old, but the is-sues debated before the Supreme Court then have risen anew today, this time behind the pharmacy counter. Following in the footsteps of the Griswold Court, we must now reaffirm that women have the right to make their own family planning decisions, including the decision to use contraception. Legislatures, pharmacy boards, pharmacies, pharmacists, and patients must work together to put the needs of patients back where they belong—as the first priority of the pharmacy profession.

Wicclair MR. The moral significance of claims of conscience in healthcare. Am J Bioeth. 2007 Dec;7(12):30-1; discussion W1-2. PubMed PMID: 18098017.

Mark R. Wicclair

  • Lawrence and Curlin (2007) argue that a major source of disagreement about the proper role of conscientious objection in medicine is traceable to differing definitions of "the conscience." To support this claim, they present two conceptions of conscience: a religious conception associated with "Abrahamic religions" (i.e., Christianity, Judaism and Islam) and a secular conception. . .

Wicclair MR. Reasons and healthcare professionals' claims of conscience. Am J Bioeth. 2007 Jun;7(6):21-2. PubMed PMID: 17558983.

Mark R. Wicclair

  • Robert Card (2007) argues against even a limited consciencebased right to refuse to dispense emergency contraception (EC) on the grounds that there are no "reasonable or justified" reasons to support such claims of conscience. This line of argument raises an important question: To what extent is it appropriate to assess reasons in relation to healthcare professionals' claims of conscience? . .

Zohar N. Moral disagreement and providing emergency contraception: a pluralistic alternative. Am J Bioeth. 2007 Jun;7(6):35-6. PubMed PMID: 17558990.

Noam Zohar

  • Robert Card (2007) concludes that healthcare workers - and in particular, pharmacists - should not be granted a right to conscientious objection with regard to providing "Plan B" or emergency contraception (EC). He argues for this conclusion by seeking to show that their objection, however it is construed, lacks substance. Because their objections to providing EC are patently wrong, they can claim no special dispensation and must fulfill their professional obligations.At first glance, this seems shockingly retrogressive. At the commencement of the modern era, protracted wars were fought in which each side tried to enforce its version of truth. The upshot of those bloody efforts - in combination with an emerging ideal of personal liberty - yielded a principle of toleration. . .