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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Antommaria AH. Adjudicating rights or analyzing interests: ethicists' role in the debate over conscience in clinical practice. Theor Med Bioeth. 2008;29(3):201-12. PubMed PMID: 18821078.

Armand H. Matheny Antommaria

  • Abstract: The analysis of a dispute can focus on either interests, rights, or power. Commentators often frame the conflict over conscience in clinical practice as a dispute between a patient's right to legally available medical treatment and a clinician's right to refuse to provide interventions the clinician finds morally objectionable. Multiple sources of unresolvable moral disagreement make resolution in these terms unlikely. One should instead focus on the parties' interests and the different ways in which the health care delivery system can accommodate them. In the specific case of pharmacists refusing to dispense emergency contraception, alternative systems such as advanced prescription, pharmacist provision, and over-the-counter sales may better reconcile the client's interest in preventing unintended pregnancy and the pharmacist's interest in not contravening his or her conscience. Within such an analysis, the ethicist's role becomes identifying and clarifying the parties' morally relevant interests.

Askin J.  Physicians need freedom of conscience. Medical Post 44.16 (Jun 13, 2008): 11-12.

Joe Askin

  • Abstract: Medically trained English philosopher Dr. John Locke (1632-1704) held that freedom of conscience is the basis of individual rights, thereby limiting intrusion by the state into the lives of its citizens. Although Canada has recognized this as the first fundamental freedom in the Charter of Rights and Freedoms, anyone who has argued a human rights case knows just how costly and trying such a suit can be.

Aultman J. Moral courage through a collective voice. Am J Bioeth. 2008 Apr;8(4):67-9; author reply W3-4. PubMed PMID: 18576265.

Julie Aultman

  • Hoas (2008), I could not help but question whether some of the ethical issues highlighted by the authors are unique to rural healthcare, such as the lack of moral courage among healthcare professionals to take action when unethical situations arise. In discussing some of these rural, ethical issues amongmycolleagues, medical residents, and students, who have observed and practiced rural healthcare, I not only confirmed what the authors thoroughly researched, but a thoughtful and reflective discussion about their own experiences and some of the unique ethical challenges they face ensued. The point is: discourse is a critical starting point for addressing and resolving these ethical problems and issues in rural healthcare. Discussions among diverse groups of rural and urban healthcare professionals and patients can foster a unified understanding of the politics, emotions, and values that continue to impair moral courage and ethical action. In this commentary I discuss various pedagogical approaches for fostering moral courage such as collective discourse, intended to serve as a companion to the three conditions, outlined by Cook and Hoas (2008), surrounding a healthcare provider's willingness to take action, including: "the extent to which one: 1) recognizes an issue as ethically problematic, 2) believes that the repercussions of one's actions can be handled, and 3) believes that positive changes will occur as a result of one's efforts" (52). . .

Beal MW, Cappiello J. Professional right of conscience. J Midwifery Womens Health. 2008 Sep-Oct;53(5):406-12; quiz 487-8. PubMed PMID: 18761293.

Margaret W. Beal, CNM, PhD, and Joyce Cappiello,

  • In recent years there have been numerous media reports of professionals attempting to expand the right of conscience and deny health care services requested by consumers. While the media has focused the most attention on pharmacists' right to refuse access to contraception, this trend is an expansion of the right originally established to protect professionals from being required to perform abortions or to provide direct assistance with abortions. State legislatures have addressed this issue, in some cases by overtly protecting consumers' rights and in other cases by broadening professional right of conscience. In this article, the literature on provider right of conscience is reviewed, and approaches advised by professional organizations are discussed.

Brock DW. Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why? Theor Med Bioeth. 2008;29(3):187-200. PubMed PMID:18756375.

Dan W. Brock

  • Abstract: Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on one's conscience. Second, I sketch an account of the basis of the medical and pharmacy professions' responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the ''conventional compromise'' as a reasonable accommodation to conflicts between these professions' responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: "Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?".

Buerki RA. The conscience clause in American pharmacy: an historical overview. Pharm Hist. 2008;50(3):107-18. PubMed PMID: 19569288.

Robert A. Buerki

  • Any consideration of the conscience clause in American pharmacy begs a consideration of the concept of "conscience," and how this moral value has affected the practice of America's pharmacists. Conscience may be seen as an inherited intuitive sense that has evolved over thousands of years of human existence, an innate sense of righ~ and wrong, or simply a set of values derive<, l. from individual experiences. There are three distinct arenas in which conscience may be exercised: individual conscience, religious conscience, and professional conscience. . .

Candib LM. More on Abortion Training Articles (Letter) Fam Med 40(1) January, 2008

Lucy M. Candib

  • As a family physician educator, I am proud to see that the editor of Family Medicine recognized theimportance of publishing the articles by Dehlendorf  and Brahmi on abortion training in family medicine residency training programs. . .

Cantor JD. Conscientious Objection Gone Awry - Restoring Selfless Professionalism in Medicine. N Egnl J Med 360;15 April 9, 2009

Julie D. Cantor

  • A new rule from the Department of Health and Human Services (DHHS) has emerged as the latest battleground in the health care conscience wars. Promulgated during the waning months of the Bush administration, the rule became effective in January. Heralded as a "provider conscience regulation" by its supporters and derided as a "midnight regulation" by its detractors, the rule could alter the andscape of federal conscience law. . .

Carlin K, Burcher B.  Conscientious Objection: An Ethical Perspective during a Health Emergency? ICNE YALE #66

Kathleen Carlin, Betty Burcher

  • Abstract: During health emergencies, whether pandemics or natural or man-made disasters, there is an increased demand for nurses and other health care workers to care for the sick or injured and to protect the well-being of the whole community. In fact, in many jurisdictions there may be emergency legislation compelling health workers to work during a crisis.  In anticipation of potential crises like a pandemic influenza, nurses have deliberated on their responsibilities during a major health emergency and have articulated that during a health emergency they would feel pulled between their obligations to their patients, their families and their own well. While during the SARS outbreak in 2003 nurses were lauded for "going above and beyond the call of duty", an alternative perspective is that "one's obligations to oneself are no less moral in character than one's obligation to others."

Historically, conscientious objection has been used to decline service in the military for moral reasons; it has also been adopted by nurses and other health professionals declining to work in patient-care areas or take part in procedures that are not compatible with their values.

This paper will examine the utility of conscientious objection as an ethical perspective during a health emergency: individual nurses deciding whether obligations to themselves and/or to their families morally outweigh professional obligations. Considering this choice as a genuine ethical dilemma may help nurses in their decision making and help others understand nurses' decisions.

Chervenak FA, McCullough LB. The ethics of direct and indirect referral for termination of pregnancy. Am J Obstet Gynecol. 2008 Sep;199(3):232.e1-3. Epub 2008 Jul 29. PubMed PMID: 18667194

Frank A. Chervenak, Laurence B. McCullough

  • Referral of pregnant patients for termination of pregnancy by physicians morally opposed to the procedure is ethically controversial, with polarized positions taken by physician organizations. Based on the ethical principles of beneficence and respect for autonomy, we establish the distinction between direct and indirect referral. Direct referral is beneficence based and requires the referring physician to ensure that the referral occurs. Indirect referral is autonomy based, with a beneficence-based component that requires that the physician provide information to the patient about health care organizations that will provide competent medical care. We show that only indirect referral is ethically required in healthy women for termination of an unwanted pregnancy or a pregnancy complicated by fetal anomalies because the indications for this procedure are solely autonomy based. Direct referral for termination of pregnancy is not ethically required but is permissible. Conscience-based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral do not.

Chervenak FA, McCullough LB. Professional responsibility and individual conscience: protecting the informed consent process from impermissible bias. J Clin Ethics. 2008 Spring;19(1):24-5. PubMed PMID: 18552049.

Frank A. Chervenak, Laurence B. McCullough

  • In their article "Of More than One Mind: Obstetrician-Gynecologists' Approaches to Morally Controversial Decisions in Sexual and Reproductive Healthcare," Farr Curlin, Shira Dinner, and Stacy Tessler Lindau report the results of a qualitative study of self-reported attitudes of obstetrician-gynecologists toward decision making in the ethically controversial clinical area of reproductive healthcare. Qualitative research is useful for the generation of significant hypothesis. Curlin, Dinner, and Lindau generate such a hypothesis: "within the one profession of obstetrics and gynecology, there are different and dissonant ideas about how a caring physician should approach medical decision making in areas of moral ambiguity." Curlin, Dinner, and Lindau are entirely correct to state: "These differences have implications for ob/ gyns and their patients. ". . .

Clark GW, Colt R, Maurer D, Latimer K, Sams RW, Zubrod, G. Integrating Abortion Training Into FM Residency Programs.  (Letter) Fam Med 40(1) January, 2008

Gary W. Clark, Ross Colt, Douglas Maurer, Kelly Latimer, Richard W. Sams II, Gordon Zubrod

  • Imagine the following introduction to a future article in Family Medicine: "Providing comprehensive care across the life cycle is a core value in family medicine. One element of comprehensive care is office- and home-based procedures. Euthanasia of the infirm elderly, mentally retarded, and disabled infants is a procedural skill well suited to the strengths of family physicians. Limited attention has been given to this procedure. Our study was designed to determine the barriers to providing euthanasia services to patients." . . .

Collier R. Morals, medicine and geography. CMAJ. 2008 Nov 4;179(10):996-7. PubMed PMID: 18981435; PubMed Central PMCID: PMC2572650.

Roger Collier

  • The US government recently proposed a rule that will force hundreds of thousands of health agencies to prove that they are not compelling doctors to perform or make referrals for - or even provide clinical information about - controversial procedures like abortion and sterilization. Health policy changes north of the 49th parallel suggest Canada is heading in a different direction. Doctors in both countries have been prompted by new guidelines to reconsider the effects of restricting physicians' freedom of conscience. Some believe it will demoralize a segment of the profession and drive many to seek new careers. Others claim that patients' rights to access legal services make restrictions necessary. . .

Curlin FA. Conscience and clinical practice: medical ethics in the face of moral controversy. Theor Med Bioeth. 2008;29(3):129-33. PubMed PMID: 18752041.

Farr A. Curlin

  • Physicians sometimes refuse to provide legally permitted medical services on the grounds that they cannot do so in good conscience. Such conscientious refusals are at least as old as the Hippocratic movement. Yet new events, such as the refusal by health care professionals to prescribe or dispense post-coital ("emergency") contraception, have kindled new debates about what physicians are obligated to do when patients request legal medical interventions to which their physicians have moral objections. In a recent national survey, we found that a large majority of physicians believe they are obligated in such circumstances to present all possible options to the patient, including information about obtaining the requested intervention, and to refer the patient to a clinician who does not object to the requested intervention. Yet a substantial minority of physicians - particularly those who are more religious and/or who themselves object to common controversial practices-disagree with these majority opinions . . .

Day AS.  Emergency contraception: when the pharmacist conscience clause restricts access. Nurs Womens Health. 2008 Aug;12(4):343-6. PubMed PMID: 18715382.

Alice S. Day

  • It was 5 p.m. on a Monday in a rural town when a 17-year-old high school senior arrived at the practice as the last walk-in patient of the day. She explained to the nurse practitioner (NP) that during sexual intercourse with her boyfriend on Friday evening, the condom had broken and she was afraid that she might become pregnant. She had been away for the weekend, arrived home late the night before and had attended a full schedule of classes on Monday. She had wanted to seek help earlier but felt she needed to be at all her classes for fear of her grades slipping and her eligibility for a college scholarship diminishing. She was hoping to be the first member of her family to go to college. . .

Dickens BM.  Conscientious commitment.  The Lancet, Volume 371, Issue 9620, Pages 1240 - 1241, 12 April 2008

  • In some regions of the world, hospital policy, negotiated with the health ministry and police, requires that a doctor who finds evidence of an unskilled abortion or abortion attempt should immediately inform police authorities and preserve the evidence. Elsewhere, religious leaders forbid male doctors from examining any part of a female patient's body other than that being directly complained about. Can a doctor invoke a conscientious commitment to medically appropriate and timely diagnosis or care and refuse to comply with such directives?

Dehlendorf C, Grumbach K, Joffe C, Brahmi D, Gold M, Engel D. Integrating Abortion Training Into FM Residency Programs.  (Author response) Fam Med 40(1) January, 2008

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

  • While we are well aware there are differences of opinion regarding the morality of abortion, as described by Clark et al, our paper was not designed to address this issue. Rather, given that abortion is legal, is within the scope of family medicine, and one of the procedures most frequently sought by our patients, we believe that family physicians should have the opportunity to receive training in this procedure if they desire. . .

de Silva DP, Jayawardana P, Hapangama A, Suraweera EG, Ranjani D, Fernando S, Karunasena C, Jinadasa S. Attitudes toward prenatal diagnosis and termination of pregnancy for genetic disorders among healthcare workers in a selected setting in Sri Lanka. 2008 Aug;28(8):715-21. doi: 10.1002/pd.2021.  PMID:18561288

  • Objectives: Assess attitudes toward prenatal diagnosis (PND) and termination of pregnancy (TOP) for Down syndrome (DS), hemophilia, lethal autosomal recessive disorder (LRD) and a hypothetical late-onset neurodegenerative disorder (NDD) among healthcare workers in one Sri Lankan district.

Methods: Self-administered questionnaire (tested for content validity) completed by medical (n = 218) and nursing (n = 368) students, nurses (n = 178) and doctors (n = 127).

Results: Acceptability of PND was 94%, 91%, 86% and 71% respectively for LRD, DS, hemophilia and NDD. Favorable attitudes toward TOP for DS (84%), and LRD (82%) were higher compared with hemophilia (65%) and NDD (53%). There was willingness to consider TOP for self/spouse for DS (79%), LRD (78%), hemophilia (60%) and NDD (54%). The proportions willing to participate in a pregnancy termination (DS 54%, LRD 51%, hemophilia 38%, NDD 38%) were lower. Religious affiliation influenced attitudes regarding TOP with Christians being more opposed than Buddhists.

Conclusions: There is acceptance of and willingness to participate in TOP for fetal anomalies among Sri Lankan healthcare workers. These findings have relevance for developing prenatal diagnostic services in Sri Lanka. Religious affiliation among Asian doctors, nurses (and patients) in developed countries is likely to determine permissiveness toward PND and TOP.

Dickens BM.  Conscientious commitment. Lancet. 2008 Apr 12;371(9620):1240-1. PubMed PMID: 18415961.

Bernard M. Dickens

  • In some regions of the world, hospital policy, negotiated with the health ministry and police, requires that a doctor who finds evidence of an unskilled abortion or abortion attempt should immediately inform police authorities and preserve the evidence. Elsewhere, religious leaders forbid male doctors from examining any part of a female patient's body other than that being directly complained about. Can a doctor invoke a conscientious commitment to medically appropriate and timely diagnosis or care and refuse to comply with such directives? . . .

Diniz D. Research Ethics in Social Sciences: Severina's Story Documentary. Int J Fem Approaches Bioeth 2008; 1(8): 23–35).

Debora Diniz

  • Abstract: In Brazil, social science research ethics is a held still under construction and subject to intense dispute. The aim of this paper is to discuss how accepted principles of biomedical research ethics can be incorporated into the ethical review of social sciences, particularly open interviews, ethnographic research, and participant observation. The paper uses a case study - the ethnographic documentary Severinas Story - as the basis for analysis of the methodological and ethical issues raised in social science research. To promote ethical social science research, based on principles such as human rights and the protection of vulnerable populations, institutional review boards must be sensitive to the epistemological and methodological particularities of all fields of human subjects research.

Flynn DP. Pharmacist conscience clauses and access to oral contraceptives. J Med Ethics. 2008 Jul;34(7):517-20. Review. PubMed PMID: 18591285.

D.P. Flynn

  • The introduction of conscience clauses after the 1973 US Supreme Court decision in Roe v. Wade allowed physicians and nurses to opt out of medical procedures, particularly abortions, to which they were morally opposed. In recent years pharmacists have requested the same consideration with regard to dispensing some medicines. This paper examines the pharmacists' role and their professional and moral obligations to patients in the light of recent refusals by pharmacists to dispense oral contraceptives. A review of John Rawls's concepts of the "original position" and the "veil of ignorance", along with consideration of the concept of compartmentalisation, are used to assess pharmacists' requests and the moral and legal rights of patients to have their prescriptive needs met.

Førde R, Aasland OG. Moral distress among Norwegian doctors. J Med Ethics. 2008 Jul;34(7):521-5. PubMed PMID: 18591286.

R. Førde R, O.G. Aasland

  • Abstract: Background: Medicine is full of value conflicts. Limited resources and legal regulations may place doctors in difficult ethical dilemmas and cause moral distress. Research on moral distress has so far been mainly studied in nurses.

Objective: To describe whether Norwegian doctors experience stress related to ethical dilemmas and lack of resources, and to explore whether the doctors feel that they have good strategies for the resolution of ethical dilemmas.

Design: Postal survey of a representative sample of 1497 Norwegian doctors in 2004, presenting statements about different ethical dilemmas, values and goals at their workplace.

Results: The response rate was 67%. 57% admitted that it is difficult to criticise a colleague for professional misconduct and 51% for ethical misconduct. 51% described sometimes having to act against own conscience as distressing. 66% of the doctors experienced distress related to long waiting lists for treatment and to impaired patient care due to time constraints. 55% reported that time spent on administration and documentation is distressing. Female doctors experienced more stress than their male colleagues. 44% reported that their workplace lacked strategies for dealing with ethical dilemmas.

Conclusion: Lack of resources creates moral dilemmas for physicians. Moral distress varies with specialty and gender. Lack of strategies to solve ethical dilemmas and low tolerance for conflict and critique from colleagues may obstruct important and necessary ethical dialogues and lead to suboptimal solutions of difficult ethical problems.

Genuis SJ. Discrimination on the basis of ethical orientation. Can Fam Physician. 2008 Dec;54(12):1679-80. PubMed PMID: 19074702; PubMed Central PMCID: PMC2602643.

Stephen J. Genuis

  • Dr. Diane Kelsall's insightful editorial "Whose right?" highlights some of the challenges associated with the policy proposed by the College of Physicians and Surgeons of Ontario (CPSO) relating to restriction of "freedom of conscience" for clinicians. It is troubling enough that the Ontario Human Rights Commission (OHRC) perceives it has the clinical perspicacity as well as the jurisdictional authority to arbitrate in complex matters relating to physician-patient relationships; it is even more perplexing that the CPSO would entertain such an infringement on their professional membership. . . .

Glasberg AL, Eriksson S, Norberg A. Factors associated with 'stress of conscience' in healthcare. Scand J Caring Sci. 2008 Jun;22(2):249-58. PubMed PMID: 18489696.

Ann-Louise Glasberg, Sture Eriksson, Astrid Norberg

  • Aim: The main purpose of this study was to examine factors related to 'stress of conscience' i.e. stress related to a troubled conscience in healthcare.

Methods: A series of questionnaires was completed by 423 healthcare employees in northern Sweden as part of this cross-sectional study. The series of questionnaires comprised the 'Stress of Conscience Questionnaire', 'Perception of Conscience Questionnaire', 'Revised Moral Sensitivity Questionnaire', Social Interactions Scale, Resilience Scale and a Personal/Work Demographic form.

Results: Nonautomatic stepwise regression analysis with forward inclusion resulted in a model that explained approximately 39.6% of the total variation in stress of conscience. Individual items associated with stress of conscience were; perceiving that conscience warns us against hurting others while at the same time not being able to follow one's conscience at work and having to deaden one's conscience to keep working in healthcare. In addition moral sensitivity items belonging to the factor 'sense of moral burden' were; one's ability to sense patient's needs means that one is doing more than one has strength for, having difficulty to deal with feelings aroused when a patient is suffering and one's ability to sense patient's needs means feeling inadequate all added significantly to the model. In addition, deficient social support from superiors, low levels of resilience and working in internal medicine wards were all associated with stress of conscience.

Conclusion: Healthcare employees seem to experience stress of conscience in their everyday practise. Particular contributing factors are not being able to follow one's conscience at work, and the 'negative' dimension of moral sensitivity – moral burden – which is an inability to deal with moral problems. Thus, in order for conscience and moral sensitivity to become an asset instead of a burden, healthcare employees need to be able to express their moral concerns.

Hardt JJ. The conscience debate: resources for rapprochement from the problem's perceived source. Theor Med Bioeth. 2008;29(3):151-60. PubMed PMID:18752040.

John J. Hardt

  • This article critically evaluates the conception of conscience underlying the debate about the proper place and role of conscience in the clinical encounter. It suggests that recovering a conception of conscience rooted in the Catholic moral tradition could offer resources for moving the debate past an unproductive assertion of conflicting rights, namely, physicians' rights to conscience versus patients' rights to socially and legally sanctioned medical interventions. It proposes that conscience is a necessary component of the moral life in general and a necessary resource for maintaining a coherent sense of moral agency. It demonstrates that an earlier and intellectually richer conception of conscience, in contrast with common contemporary formulations, makes the judgments of conscience accountable to reason, open to critique, and protected from becoming a bastion for bigotry, idiosyncrasy, and personal bias.

Johnstone MJ. Abortion and the politicisation of conscience.  Dec 08/Jan 09, 16(6) Aust Nurs J 21

Megan-Jane Johnstone

  • On 10 October 2008 following a highly charged emotional debate and an historic conscience vote in State Parliament, abortion was decriminalised in Victoria. For many observers this reform was long overdue and simply brought the law into line with common practice in Victoria. It also meant that women having abortions and the doctors who performed them no longer risked criminal prosecution, which if successful carried a penalty of up to 10 years jail, a consequence that supporters regarded as unconscionable. . .

Juthberg C, Eriksson S, Norberg A, Sundin K. Stress of conscience and perceptions of conscience in relation to burnout among care-providers in older people. J Clin Nurs. 2008 Jul;17(14):1897-906. PubMed PMID: 18592617.

Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin

  • Aims. The aim was to study the relationship between conscience and burnout among care-providers in older care, exploring the relationship between stress of conscience and burnout, and between perceptions of conscience and burnout.

Background. Everyday work in healthcare presents situations that influence careproviders' conscience. How care-providers perceive conscience has been shown to be related to stress of conscience (stress related to troubled conscience), and in county council care, an association between stress of conscience and burnout has been found.

Method. A questionnaire study was conducted in municipal housing for older people. A total of 166 care-providers were approached, of which 146 (50 registered nurses and 96 nurses' aides/enrolled nurses) completed a questionnaire folder containing the stress of conscience questionnaire, the perceptions of conscience questionnaire and the maslach burnout inventory. Multivariate canonical correlation analysis was used to explore relationships.

Result. The relationship between stress of conscience and burnout indicates that experiences of shortcomings and of being exposed to contradictory demands are strongly related to burnout (primarily to emotional exhaustion). The relationship between perceptions of conscience and burnout indicates that a deadened conscience is strongly related to burnout.

Conclusion. Conscience seems to be of importance in relation to burnout, and suppressing conscience may result in a profound loss of wholeness, integrity and harmony in the self.

Relevance to clinical practice. The results from our study could be used to raise awareness of the importance of conscience in care.

Lamačková A. Conscientious objection in reproductive health care: Analysis of Pichon and Sajous v. France. Eur J Health Law. 2008 May;15(1):7-43. PubMed PMID: 18630725.

Adriana Lamačková

  • Abstract: This article explores the issue of conscientious objection invoked by health professionals in the reproductive and sexual health care context and its impact on women's ability to access health services. The right to exercise conscientious objection has been recognized by many international and European scholars as being derived from the right to freedom of thought, conscience and religion. It is not, however, an absolute right. When the exercise of conscientious objection conflicts with other human rights and fundamental freedoms, a balance must be struck between the right to conscientious objection and other affected rights such as the right to respect for private life, the right to equality and non-discrimination, and the right to receive and impart information. Particularly in the reproductive health care context, states that allow health professionals to exercise conscientious objection must accommodate this in such a way that its exercise does not compromise women's access to health services. Th is article analyses the European Court of Human Rights' decision on admissibility in Pichon and Sajous v. France (2001) and argues that a balancing approach should be applied in cases of conscientious objection in the sexual and reproductive health care context.

Lantos JD, Curlin FA. Religion, conscience and clinical decisions. Acta Paediatr. 2008 Mar;97(3):265-6. PubMed PMID: 18298771.

John D. Lantos, Farr A. Curlin

  • Consider the following three cases: A paediatrician is called to the delivery room as a woman is about to give birth to a premature baby at 24 weeks. The mother and father request that the baby not be resuscitated. The baby weighs 760 grams and has an Apgar score of 6 at 1 min. The paediatrician ignores the parents' requests for comfort care and intubates the baby.

A full-term baby with Trisomy 18 develops cyanosis. An echocardiogram reveals a large ventricular septal defect. The parents request surgery. The cardiac surgeon refuses to operate based upon the baby's poor prognosis for a 'reasonable quality of life.'

A 15-year old girl is seen for a sports physical. She asks for a prescription for birth control pills and asks the paediatrician not to tell her parents that she is sexually active or using oral contraceptives. The doctor refuses to prescribe the pills without parental permission. . .

Lipp, A. A review of termination of pregnancy: prevalent health care professional attitudes and ways of influencing them. Journal of Clinical Nursing, 17(13), pp: 1683-1688.

Allyson J. Lipp

  • Abstract: Aim: To review the literature on attitudes of health care professionals to termination of pregnancy and draw out underlying themes.

Background: The controversy surrounding therapeutic abortion is unremitting with public opinion often polemic and unyielding. Nurses and midwives are at the centre of this turmoil, and as more termination of pregnancies are being performed using pharmacological agents, they are becoming ever more involved in direct care and treatment. Attitudes towards termination of pregnancy have been found to vary depending on the nationality of those asked, the professionals involved, experience in abortion care, as well as personal attributes of those asked such as their obstetric history and religious beliefs. The reasons for women undergoing abortion were also found to influence attitudes to a greater or lesser extent.

Conclusion: This paper explores research studies undertaken into attitudes of health care professionals towards termination of pregnancy, to appreciate the complexity of the debate. It is possible that the increased involvement of nurses in termination of pregnancy, that current methods demand, may lead to change in attitudes. Consideration is given to a number of remedies to create an optimum environment for women undergoing termination of pregnancy.

Relevance to clinical practice: This paper establishes via a literature review that attitudes in those working in this area of care depend upon a variety of influences. Suggestions are made for measures to be put into place to foster appropriate attitudes in those working in termination of pregnancy services.

Mirkes R. Protecting the right of informed conscience in reproductive medicine. J Med Philos. 2008 Aug;33(4):374-93. PubMed PMID: 18662951.

Renée Mirkes

  • This essay sets down three directives for conscientiously objecting clinicians - physicians, particularly obstetrician/gynecologists, trained in NaProTechnology by the Pope Paul VI Institute and Creighton University School of Medicine and any medical professionals who share their natural law vision of reproductive health care- to protect their right to well-formed conscientious objection in reproductive medicine. Directive one: understand the nature of a wellformed conscience and its rightful exercise. Directive two: fulfill all reasonable American College of Obstetricians and Gynecologists' requirements for conscientious refusal. Directive three: execute a political strategy to protect health-care conscience rights.

Powell T. LVADs and the limits of autonomy. (Letter) Hastings Cent Rep. 2008 May-Jun;38(3):4-5; author reply 5. PubMed PMID: 18584849.

Tia Powell

  • I read with concern the recent case study ("Doctor, Will You Turn Off My LVAD?" Jan-Feb 2008) regarding deactivation of LVADs. Jere my Simon's commentary argues that physicians may decline to deactivate an LVAD even at the request of a capable patient. He finds that the patient's right to decline any and all medical treatment does not apply here since the LVAD, once implanted, is no longer a treat ment, but more like a patient's organ. . .

Sarkar NN. Barriers to emergency contraception (EC): does promoting EC increase risk for contacting sexually transmitted infections, HIV/AIDS? Int J Clin Pract. 2008 Nov;62(11):1769-75. Review. PubMed PMID: 19143861.

N.N. Sarkar

  • Objective: The aim of this study was to focus on barriers, controversy and perceived risk associated with use of emergency contraception (EC) after unprotected sexual intercourse.

Design and method: Data were extracted from the literature of the MEDLINE database service. Original articles, surveys, clinical trials and investigations are considered for this review.

Results: After the introduction of over-the-counter and advance prescription provisions for easy access to EC, the rural– urban disparity in availability of EC poses a barrier to use of EC for rural dwellers. The socio-economically weaker section of the population is unable to purchase EC because of low or no income, although there is mounting pressure by the State for prevention of unintended pregnancy by use of EC. Some healthcare providers have objected to provide EC to the patient on the grounds of their conscience and morality. Some providers and users have also expressed concerns about the possibility of increase in irresponsible sexual behaviour because of easy access to EC. There may be some truth in their apprehension because nearly 3.2 million unintended pregnancies occur annually despite various contraceptive options available in USA and the extensive use of EC is directly proportional to the volume of unprotected sexual intercourse, which is too directly proportional to the quantum of risk for contacting sexually transmitted infections (STIs) ⁄ AIDS.

Conclusions: Emergency contraception is a one-off postcoital procedure and not to be opted after every sexual intercourse. Controversy about EC may be resolved if it is used within this limit. Extensive use of EC may increase risk for contacting STIs ⁄ AIDS.

Simon J, Fischbach R.  LVADs and the limits of autonomy. (Author reply) Hastings Cent Rep. 2008 May-Jun;38(3):4-5; author reply 5. PubMed PMID: 18584849

Jeremy Simon, Ruth Fischbach

  • We thank Tia Powell for responding to our case commentary, but we are puzzled by the strength of her reaction to Jeremy Simon's argument. We do not consider its suggestions to be outside the bounds of law or ethics. To make the argument sharper, consider an internally powered, fully self-contained, implantable artificial heart with no external connections, which, while not currently available, is certainly not fantasy. Powell would argue that a patient has the right to have this device removed should he desire. We believe that this claim is debatable, as we do not see a clear ethical difference between a fully implanted mechanical heart and a transplanted biological heart, which no physician would remove, even at a patient's request. . .

Sperling D. [Conscience, principled refusal and ethics of refusal to provide treatment to a patient's request]. Harefuah. 2008 May;147(5):398-402, 479. Hebrew. PubMed PMID: 18770960.


Sperling D. Law and Bioethics: A Rights-Based Relationship and its Troubling Implications (December 22, 2008). Current Legal Issues, Vol. 11, pp. 52-78, 2008.

Daniel Sperling

Abstract: Some argue that law is the discipline which has mixed most prominently with bioethics, and that bioethicists can be seduced by the law and by legal procedures. While there is a great consensus that law has influenced bioethics in significant and important ways, certainly much more than it influenced other "law and..." disciplines, scholars dispute as to the exact role which the law plays in bioethics, the goals it purports to achieve and the implications of its relationship with the discipline of bioethics. This Article aims to explore the relationship between law and bioethics and calls for a careful evaluation of the law's contributions to bioethics. Specifically, it will be argued that while the law contributed extensively to the development of bioethics it introduced a language and a way of thinking that are not necessarily appropriate to handle and resolve bioethical issues, and which, in significant portion of cases, was irrelevant and had little impact on decision-making and behavioral patterns of patients. Moreover, law's interference with and shape of bioethical issues resulted in serious threats to some of the major characteristic of such issues and brought about to other societal concerns which the law did not consider seriously. The article will conclude that it is now time to re-evaluate the direction in which bioethics should take in the next years, specifically whether it should continue to integrate with law or other disciplines, or alternatively become a more autonomous and independent discipline.

Spreng JE. Pharmacists and the "Duty" To Dispense Emergency Contraceptives. 23 Issues L. & Med. 215 (Spring, 2008)

Jennifer E. Spreng

Abstract: Stories abound of both women with prescriptions turned away at the pharmacy door and members of the most trusted health care profession losing jobs and running afoul of ethics rules. Scholars have spilt much intellectual ink divining whether a pharmacist must dispense Plan B, the primary emergency contraceptive. Now, many are calling for a common law "duty to dispense" that could serve as a foundation for a wrongful pregnancy action against a dissenting pharmacist. Such a duty simply does not arise from established tort principles or pharmacist-specific precedents. Only in rare circumstances will a pharmacist and customer have the type and quality of relationship giving rise to a duty to dispense. Nevertheless, law changes over time and makes allowances for unique circumstances. Pharmacists are taking on more responsibility for drug therapy. They have an awkward role in the distribution of Plan B. Moreover, while the law may protect pharmacists' consciences, it may not be so receptive to pharmacists-as-activists. Dissenting pharmacists can take practical steps to protect themselves today, but tomorrow is another day.

Spreng JE.  Conscientious Objectors Behind the Counter: Statutory Defenses to Tort Liability for Failure to Dispense Contraceptives. 1 St. Louis U. J. Health L. & Pol’y 337, 337-40 (2008)

  • Introduction:  The United States Food and Drug Administration’s decisions in the past
    decade to approve both RU-486 and Plan B have created crises of conscience for some religious pharmacists. RU-486 induces abortion in the first trimester of pregnancy without surgical intervention and Plan B is a two-pill "emergency contraceptive" regimen that may have abortifacient properties. Some religious pharmacists prefer not to dispense the drugs because their religious scruples forbid them from participating in abortions.  Some also object to dispensing daily oral contraceptives6 on the same basis.

Suenaga K. [Shomatsu Yokoyama, a physiologist who refused to conduct experiments on living human bodies]. Nippon Ishigaku Zasshi. 2008 Sep;54(3):239-48. Japanese. PubMed PMID: 19244742.

Keiko Suenaga

  • This article introduces the life of Shomatsu Yokoyama ( 1913-1992), a physiologist and military doctor, to the reader. During the Sino-Japanese war, Yokoyama disobeyed orders given by his superior officer to conduct inhumane medical experiments on humans.

Not only in Unit 731, but also in other units, many military doctors were involved in medical crimes against residents of the areas invaded by the Japanese Army. Inhumane living-body experiments and vivisections were widely conducted at that time.

There were, however, a small number of researchers who did not follow the orders to perform human body experiments. Highlighting the life of such a rare researcher for the purpose of ascertaining the reason for his noncompliance with the order will provide us with insights on medical ethics.

When Yokoyama was a student, his teacher, Professor Rinya Kawamura, informed him that he had been requested by the army to conduct special experiments. The remuneration for conducting such experiments was over 10 times more than the research fund allocated to the professor. Kawamura declined the request on the grounds that accepting it was against humanity. Kawamura warned Yokoyama that he might face the same situation in the future and asked Yokoyama to mark his words.

Yokoyama was called to Ko-1855 Unit in 1944 and ordered to carry out living-body experiments by his superior officer. He disregarded the order, remembering Kawamura's words. As a result, he was dispatched to the dangerous frontlines.

This article explores why Yokoyama was able to disobey the order to conduct inhumane experiments while shedding light on his personal background and his relationship with Rinya Kawamura. This article chronicles the life of one medical researcher who followed the dictates of his conscience during and after the war.

Sulmasy DP. What is conscience and why is respect for it so important? Theor Med Bioeth. 2008;29(3):135-49. PubMed PMID: 18758994.

Daniel P. Sulmasy

  • Abstract: The literature on conscience in medicine has paid little attention to what is meant by the word 'conscience.' This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one's ability, and (2) the activity of judging that an act one has done or about which one is deliberating would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed.

Tsai AC. Public-private distinctions in matters of conscience. (Letter) Am J Bioeth. 2008 Feb;8(2):W7. PubMed PMID: 18570068.

Alexander C. Tsai

  • Savulescu's analysis and comment on conscientious objection in medicine would benefit from a more carefully drawn distinction between conscientious objectors in the public vs. private sector. Savulescu (2007) writes that physician conscientious objection could affect "potentially 40 million American patients" and refusal to refer could affect "potentially 100 million American patients", but he makes no distinction between whether they are seeking care in the public vs. private sector. . .

Tully P. Morally Objectionable Options Informed Consent and Physician Integrity.  National Catholic Bioethics Quarterly, Autumn, 2008 491-504 

Patrick A. Tully

  • Recent and forthcoming medical technologies and practices (e.g., in vitro fertilization, somatic cell nuclear transfer, oocyte-assisted reprogramming, the creation of chimeras and "savior siblings") are likely to multiply the occasions for a type of dilemma that physicians have long faced: What are doctors to do when a treatment that they believe to be seriously morally wrong is available and indicated for one of their patients? . . .

von Kohlen H.   Hospital ethics committees in the USA and in Germany: bioethics qua practice, nurses' participation and the issues of care.  Dissertation, 4 April, 2008.  Faculty of Philosophy, Gottfried Wilhelm Leibniz University, Hannover. Examiner: Prof. Dr. Kathrin Braun; Co-examiner: Prof. Dr. Barbara Duden. 

Helen von Kohlen

  • Abstract: In this work the institutionalisation of Hospital Ethics Committees in the USA and in Germany will be analysed by focussing on nurses' participation and the representation of caring issues. Therefore, questions about the design of Hospital! Ethics Committees and how their practices really look like, will be raised. The central question is, how the tradi­tional care ethos of the helping professions in medicine and nursing can find its place in discussions of these committees while hospitals have increasingly been organised along economic criteria.

The comparative research combines a literature study, expert interviews and histori­cal analysis of Hospital Ethics Committees in the USA (first part) with an investigation into theoretical approaches that understand care as a practice (second part). The empirical study of Ethics Committees in Germany took place over two years in three Ethics Com­mittees in a Lutheran hospital, a Catholic hospital and a Communal one that had been privatised. The field study is based on participant observations and interviews.

For the overall research, Adele Clarke's work of Situational Analysis: (2005) proved to be fundamental since it offered to combine historical, conceptual and ethnographic ap­proaches. The gathered data were structured and interpreted in the framework of qualitative content analysis.

The analysis of the US- American development shows under which influences a new type of consultation, namely multidisciplinary ethics consultation as a shared-deci­sion-making process could unfold. Personal fates like the story of Karen Quinlan and the so-called "Baby-Doe-Cases" contributed to the establishment of Hospital Ethics Committees. An acceleration of the growth of these committees were accreditation processes of hospitals that would demand such an instrument to deal with ethical conflicts. US­ American governmental intervention could also support its development, mainly to prevent law-suits.

Nurses' participation in US- American Hospital Ethics Committees has been a mat­ter of concern since the 1980is. Studies could show that nurses were members of these committees, but they would not bring in their unique ethical issues. In order to focus more on nurses' specific conflicts, between 1980 and 1990 Nursing Ethics Committees were established. Discussions in Hospital Ethics Committees were framed by a principle based model. Respect for autonomy became the leading principle. Hereby, conflicts with regard to a practices of care were rather marginalized. Nevertheless, a debate about care ethics took place in the nursing scientific community when Carol Gilligan had published her research In a Different Voice (1982). In the 1990's mainly political (feminist) ethicists worked on theoretical approaches to understand care as a practice. The refined under­standing of care by Joan Trento, Margaret Urban Walker and Elisabeth Conradi were especially helpful to describe the unseen work of care in the data given by the participant observations.

 My observations and Interviews in the field work show that care practices in the tradition of Hippocratic Medicine are no longer self-evident for the helping professions. Physicians and nurses do rather struggle for a care ethos especially with regard to end-of-life questions and regulations of tube-feeding. The "cases" for ethics consultation brought into the committees by physicians and nurses did not rarely emerge as social problems and as a lack of professional competence. The problems appeared to be solvable by trans­lating them into a language of principles and making the process manageable. These principle-based discussions in the practical arena of the hospital resemble discourse practices embedded within the larger bioethical debates on the political arena. Technical proce­dures given my management and administration do fit into the use of abstract principles and contribute to a language that limits the possibilities to think - what is at stake for patients - in terms of caring relations rather than thinking in terms of rules, regulations and control.

Wernow JR, Grant DG. Dispensing with conscience: a legal and ethical assessment. Ann Pharmacother. 2008 Nov;42(11):1669-78. Epub 2008 Oct 21. Review. PubMed PMID: 18940917.

Jerome R. Wernow, Donald G. Grant

  • Background: For over 30 years, pharmacists have exercised the right to dispense medications in accordance with moral convictions based upon a Judeo- Christian ethic. What many of these practitioners see as an apparent shift away from this time-honored ethic has resulted in a challenge to this right.

Objective: To review and analyze pharmacy practice standards, legal proceedings, and ethical principles behind conflicts of conscientious objection in dispensing drugs used for emergency contraception.

Data sources: We first searched the terms conscience and clause and Plan B and contraception and abortion using Google, Yahoo, and Microsoft Networks (2006–September 26, 2008). Second, we used Medscape to search professional pharmacy and other medical journals, restricting our terms to conscience, Plan B, contraceptives, and abortifacients. Finally, we employed Loislaw, an online legal archiving service, and did a global search on the phrase conscience clause to determine the status of the legal discussion.

Data synthesis: To date, conflicts in conscientious objection have arisen when a pharmacist believes that dispensing an oral contraceptive violates his or her moral understanding for the promotion of human life. Up to this time, cases in pharmacy have involved only practitioners from orthodox Christian faith communities, primarily devout Roman Catholics. A pharmacist's right to refuse the dispensing of abortifacients for birth control according to moral conscience over against a woman's right to reproductive birth control has created a conflict that has yet to be reconciled by licensing agents, professional standards, or courts of law.

Conclusions: Our analysis of prominent conflicts suggests that the underlying worldviews between factions make compromise improbable. Risks and liabilities are dependent upon compliance with evolving state laws, specific disclosure of a pharmacist's moral objections, and professionalism in the handling of volatile situations. Objecting pharmacists and their employers should have clear policies and procedures in place to minimize workplace conflicts and maximize patient care.

Wicclair MR. Is conscientious objection incompatible with a physician's professional obligations? Theor Med Bioeth. 2008;29(3):171-85. PubMed PMID: 18752039

Mark R. Wicclair

Abstract: In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician's professional obligations (the "incompatibility thesis"). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal morality (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician's professional obligations unequivocally supports the incompatibility thesis.

Wilson RF. Essay: the limits of conscience: moral clashes over deeply divisive healthcare procedures. Am J Law Med. 2008;34(1):41-63. PubMed PMID: 18512536

Robin Fretwell Wilson

  • Introduction: Refusals by individual pharmacies and pharmacists to fill prescriptions for emergency contraceptives ("EC") have dominated news headlines, from the Washington Post to the Miami Herald. In the act that sparked a firestorm of controversy, an Eckerd pharmacist refused to fill a rape victim's prescription for Plan B. A few months later, 11 Alabama nurses resigned positions at state clinics rather than provide EC against their moral convictions. These refusals do not seem to be driven by moral concerns about promiscuity, since pharmacists have refused to dispense Plan B to married couples as well. Instead, the refusals reflect moral and religious concerns about facilitating an act that would cut-off a potential human life. . .