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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Barilan, Y. Michael A., Brusa, Margherita. Triangular Reflective Equilibrium: A Conscience-Based Method for Bioethical Deliberation. Bioethics, Volume 25 Number 6 2011 pp 304-319.

  • Abstract:  Following a discussion of some historical roots of conscience, we offer a systematized version of reflective equilibrium. Aiming at a comprehensive methodology for bioethical deliberation, we develop an expanded variant of reflective equilibrium, which we call 'triangular reflective equilibrium' and which incorporates insights from hermeneutics, critical theory and narrative ethics.

We focus on a few distinctions, mainly between methods of justification in ethics and the social practice of bioethical deliberation, between coherence in ethical reasoning, personal integrity and consensus formation, and between political and moral deliberation. The ideal of deliberation is explicated as a sharing of conscience within a special commitment to sincerity and openness to persuasion. Personal growth in wisdom is an indirect by-product of the continuous practice of moral deliberation. This is explicated in the light of Sternberg's balance theory of wisdom and in the context of medicine as a profession embodying altruistic responsibilities of care in democratic and pluralistic societies.

Blum R. Conscience rules: implications for care: Should conscience always be our guide?. Hastings Cent Rep. 2011 May-Jun;41(3):49. PubMed PMID: 21678815.

  • On February 18, the Department of Health and Human Services issued a rule, "Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws," that limits health care providers' power to shape their practice by personal conviction. The rule narrows possible conscientious objection significantly, protecting patients' rights and in the process eliminating public reinforcement of the harmful idea that religion and medicine are always destined to diverge. . .

Card RF. Conscientious objection, emergency contraception, and public policy.  J Med Philos. 2011 Feb;36(1):53-68. Epub 2011 Jan 17. PubMed PMID: 21242325.

  • Abstract: Defenders of medical professionals' rights to conscientious objection (CO) regarding emergency contraception (EC) draw an analogy to CO in the military. Such professionals object to EC since it has the possibility of harming zygotic life, yet if we accept this analogy and utilize jurisprudence to frame the associated public policy, those who refuse to dispense EC would not have their objection honored. Legal precedent holds that one must consistently object to all forms of the relevant activity. In the case at hand, then, I argue that these professionals must also oppose morally innocuous practices that may prevent pregnancy after fertilization. These results reveal that such objectors cannot offer a plausible and consistent objection to harming zygotic life. Additionally, there are good reasons to reject the analogy itself. In either case, these findings call into question the case supporting refusals of EC based on scruples.

Conway BV, Should doctors feel able to practise according to their personal views and beliefs?-Yes. MJA 2011; 195 (9): 496-497 doi: 10.5694/mja11.11234

  • The child lies in the hospital, defeated by cancer and on the edge of death. Clinicians advise that there is nothing more to do beyond keeping her comfortable. The parents disagree. Wanting absolutely everything done, they secure a court order to enforce their wishes. With every cardiac arrest, the treating team reluctantly sets to work. She has already arrested nearly 10 times through the day and staff dread the next code. . .

Fragoso M, Taking Conscience Seriously or Seriously Taking Conscience?: Obstetricians, Specialty Boards, and the Takings Clause, 86 Notre Dame L. Rev. 1687 (2011).

  • Introduction: A young woman visits her local obstetrician. She tells him that she suspects, based on a home pregnancy test, that she is pregnant.  Unwed and scared, she hesitated before seeing a doctor. The obstetrician examines her and tells her that she is, indeed, two months pregnant. The young woman says that she would like the pregnancy terminated and asks him if he will perform the procedure. The doctor, an observant Jew, informs her that had she visited sooner he might have been able to accommodate her request (as his particular religious beliefs do not attribute full human dignity to the embryo until it has gestated for forty days), but at this stage in the pregnancy he is unable to do so in good conscience, as that would involve the taking of human life. Furthermore, uncomfortable participating remotely in an abortion, the obstetrician does not refer the woman to a specific alternate obstetrician; he instead assures her that there are plenty of other nearby doctors who would be willing to perform the procedure and that she should ask around.

Grönlund CECF, Dahlqvist V, Soderberg AIS.  Feeling trapped and being torn: Physicians' narratives about ethical dilemmas in hemodialysis care that evoke a troubled conscience.  BMC Medical Ethics 2011, 12:8

Catarina EC Fischer Grönlund, Vera Dahlqvist, Anna IS Söderberg

  • Abstract:  Background: This study is part of a major study about difficulties in communicating ethical problems within and among professional groups working in hemodialysis care. Describing experiences of ethically difficult situations that induce a troubled conscience may raise consciousness about ethical problems and thereby open the way to further reflection. The aim of this study was to illuminate the meanings of being in ethically difficult situations that led to the burden of a troubled conscience, as narrated by physicians working in dialysis care.

Method: A phenomenological hermeneutic method was used to analyze the transcribed narrative interviews with five physicians who had varying lengths of experience in nephrology.

Results: The analysis shows that physicians working in hemodialysis care suffered from a troubled conscience when they felt torn by conflicting demands and trapped in irresolution. They faced ethical dilemmas where they were forced to make crucial decisions about life or death, or to prioritize when squeezed between time restraints and professional and personal demands. In these ethical dilemmas the physicians avoided arousing conflicts, were afraid of using their authority, were burdened by moral responsibility and felt devalued and questioned about their way of handling the situation. The findings point to another way of encountering ethical dilemmas, being guided by their conscience. This mean sharing the agony of deciding how to act, being brave enough to bring up the crucial problem, feeling certain that better ways of acting have not been overlooked, being respected and confirmed regarding decisions made.

Conclusion: The meanings of being in ethically difficult situations that led to the burden of a troubled conscience in those working in hemodialysis care, indicate the importance of increasing the level of communication within and among various professional groups - to transform being burdened by a troubled conscience into using conscience as a guide - in situations where no way of solving the problem seems to be good.

Kelly EP, Ellis AD, Rosenthal SPS. Crisis of Conscience: Pharmacist Refusal to Provide Health Care Services on Moral Grounds. Employ Respons Rights J (2011) 23:37–54 DOI 10.1007/s10672-010-9142-2

  • Abstract: Advances in technology have resulted in medical procedures and practices that were unthought-of in previous generations. Embryonic stem cell research, abortifacients, birth control, and artificial insemination are just a few examples of these technological advances. While many individuals readily embrace such medical advances, others find them morally objectionable. A contentious national debate is now occurring over whether employee pharmacists have the right to refuse to fill legal prescriptions for emergency contraception because of conscientious objections. In the United States, existing public policy is somewhat muddled in both protecting and encroaching on the employee pharmacist's right of refusal. This article discusses the legal and ethical nature of that controversy, as well as the clash of interests, rights and responsibilities between employers, employee pharmacists and customers from a U.S. perspective.

Ko HK, Wang RH. [Unity of knowing and action- exploring moral courage in nursing practice]. Hu Li Za Zhi. 2011 Feb;58(1):102-7. Chinese. PubMed PMID: 21328213.


Groll D, What Health Care Providers Know: A Taxonomy of Clinical Disagreements. Hastings Center Report 41, no. 5 (2011): 27-36.

  • Consider the following case: Horace Johnson is a forty-year-old, wheelchair-bound patient who has been suffering for the past ten years from type 2 diabetes mellitus. He has wet gangrene on his fifth toe. He doesn't visit the outpatient clinic for care of his diabetes and infection as he is scheduled to. The infection is so severe that his physician,
    Dr. Garcia, concludes that the toe cannot be saved and that if it is not amputated, Mr. Johnson could die. Mr. Johnson has been seen by a psychiatrist, who finds him eccentric but believes that he has no evidence of mental illness and must therefore be declared
    competent to make his own health care decisions. . .

Parker JC. Conscience and collective duties: do medical professionals have a collective duty to ensure that their profession provides non-discriminatory access to all medical services? J Med Philos. 2011 Feb;36(1):28-52. Epub 2011 Jan 10. PubMed PMID: 21220522.

  • Recent debates have led some to question the legitimacy of physicians refusing to provide legally permissible services for reasons of conscience. In this paper, I will explore the question of whether medical professionals have a collective duty to ensure that their profession provides nondiscriminatory access to all medical services. I will argue that they do not. I will also argue for an approach to dealing with intractable moral disagreements between patients and physicians that gives both parties veto power with regards to participation. Finally, I will respond to three objections to allowing physicians broad freedom to act on their consciences: such allowances would violate the conscience of the patient, would lead to unfairness, and would thwart important societal goals.

Parkinson 34 U.N.S.W.L.J. 281 (2011)
Accommodating Religious Belief in a Secular Age: The Issue of Conscientious Objection in the Workplace, Am, Patrick Parkinson
[ 19 pages, 281 to 299 ]

Poreda M. Reforming New Jersey's vaccination policy: the case for the Conscientious Exemption Bill. Seton Hall Law Rev. 2011;41(2):765-811. PubMed PMID: 21739762.

  • Introduction:  When New Jersey became the first state to require a flu vaccine for children in 2008, parents protested outside the State House. The new mandate requires children between six months and five years old to get an annual flu shot to attend a child care facility or day care center. According to state epidemiologist Dr. Eddy Bresnitz, New Jersey based its decision to require flu vaccines for preschoolers on recommendations by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA).

Savulescu J, Should doctors feel able to practise according to their personal values and beliefs? - No. MJA 2011; 195 (9): 497 doi:0.5694/mja11.11249

  • Conscientious objection by doctors, as is commonly practised, is discriminatory medicine. Only a fully justified and publicly accepted set of objective values results in ethical medicine as a proper public service with agreed and justified moral and legal standards to which doctors should be held. . .

Shu LL, Gino F, Bazerman MH. Dishonest deed, clear conscience: when cheating leads to moral disengagement and motivated forgetting. Pers Soc Psychol Bull. 2011 Mar;37(3):330-49. PubMed PMID: 21307176.

  • Abstract:  People routinely engage in dishonest acts without feeling guilty about their behavior. When and why does this occur?  Across four studies, people justified their dishonest deeds through moral disengagement and exhibited motivated forgetting of information that might otherwise limit their dishonesty. Using hypothetical scenarios (Studies 1 and 2) and real tasks involving the opportunity to cheat (Studies 3 and 4), the authors find that one's own dishonest behavior increased moral disengagement and motivated forgetting of moral rules. Such changes did not occur in the case of honest behavior or consideration of the dishonest behavior of others. In addition, increasing moral saliency by having participants read or sign an honor code significantly reduced unethical behavior and prevented subsequent moral disengagement. Although dishonest behavior motivated moral leniency and led to forgetting of moral rules, honest behavior motivated moral stringency and diligent recollection of moral rules.

McGuinness S. Commentary: Problems of patient and professional responsibilities. Camb Q Healthc Ethics. 2011 Jan;20(1):147-9; discussion 143. PubMed PMID: 21223621.

  • This case raises a wealth of interesting issues about duties and responsibilities between healthcare practitioners and patients. I will deal in turn with each of the objections raised by the clinicians to treating Mr. C and sum up with a brief consideration of the clinicians who wished to treat Mr. C. The purpose of this commentary is not to give a definitive answer to how clinicians should deal with cases like Mr. C's, but rather to tease out some of the ethical issues raised in this scenario.

von Bergen CW, Bressler M.  A matter of conscience: do conflicting beliefs and workplace
demands constitute religious discrimination?
Journal of Behavioral Studies in Business, 3 (1 April 2011)1-14

  • Abstract: Increasingly, employees maintain they should be provided an unqualified legal right to refuse work activities that violate their ethical, moral, personal, or religious convictions or beliefs - in short, their conscience. This assertion has become one of the more controversial issues confronting employers. This paper presents a brief review of conscientious objection with special attention to objection in medical related areas, followed by new discussion of freedom of conscience in the workplace.

White DB, Brody B. Would accommodating some conscientious objections by physicians promote quality in medical care? JAMA. 2011 May 4;305(17):1804-5. PubMed PMID: 21540425.

  • Moral pluralism is a valuable aspect of a free society but sometimes creates conflicts in medical care when individual physicians object to providing certain legal but morally
    controversial services, such as abortion, physician-assisted suicide (where it is legal), and palliative sedation to unconsciousness.  Genuine conscience-based refusals (CBRs) are
    refusals in which a physician believes that providing the requested service would violate his or her core moral beliefs (religious or secular), thereby causing personal moral harm. Conscience-based refusals should be a "shield" to protect individual physicians from being compelled to violate their core moral beliefs rather than a "sword" to force their beliefs onto patients. This partially explains why many physicians who invoke CBRs refer their patients to physicians willing to provide the requested care.

Wicclair MR. Conscientious refusals by hospitals and emergency contraception. Camb Q Healthc Ethics. 2011 Jan;20(1):130-8. PubMed PMID: 21223617.

  • Hospitals sometimes refuse to provide goods and services or honor patients' decisions to forgo life-sustaining treatment for reasons that appear to resemble appeals to conscience. For example, based on the Ethical and Religious Directives for Catholic Health Care Services (ERD), Catholic hospitals have refused to forgo medically provided nutrition and hydration (MPNH), and Catholic hospitals have refused to provide emergency contraception (EC) and perform abortions or sterilization procedures. I consider whether it is justified to refuse to offer EC to victims of sexual assault who present at the emergency department (ED). A preliminary question, however, is whether a hospital's refusal to provide services can be conceptualized as conscience based.

Wicclair MR. Commentary: Rights, professional obligations, and moral disapproval. Camb Q Healthc Ethics. 2011 Jan;20(1):144-7; discussion 143. PubMed PMID: 21223620.

  • This case presents several important ethical issues. One concerns the response to Mr. C when he asked whether there was any way to ''speed up'' the process so that he would not have to wait several years to receive a liver transplant. He was told that shortening his wait time was ''not possible,'' and he only learned about the China option from ''discussions with friends.'' Was it ethically acceptable for transplant physicians who knew about the China option but disapproved of it to withhold information about it from Mr. C?

Young-Mason J. Betrayal of conscience. Clin Nurse Spec. 2011 Jan-Feb;25(1):49. PubMed PMID: 21139468.

  • There are many instances when nurses face situations of violence in which there is both a perpetrator and a victim. Violence takes many forms and occurs in domestic and public domain and in the extreme situation of war.

The noted French scholar and Islamicist, LouisMassignon, in his writings during the French Algerian War, asks us to consider Gandhi's concern that assuming moral superiority
in any confrontation can lead to further violence.

"Why is there this apparent flaw in nonviolence for witnessing truth (and, what is indispensable, all truth)? Gandhi explained it by observing that a brutal witnessing in favor of truth, using apparent physical nonviolence, opens the war to a spiritual violence, to a weapon more
menacing than the worst material weapons. When we use truth as a privilege and monopoly to force an adversary to humiliate himself as a liar, then the flickering conscience which he has even in his most indefensible physical violence is unable to submit to our truth because we have refused to recognize that he has a conscience at all."