While intended primarily for medical, pharmacy and nursing students,
what follows may be of assistance to others studying for a career in
health care or practitioners already in the field.
Table of Contents
II. Identify objectionable
III. Articulate the
basis for your objections
IV. Establish the
extent of your objections
V. Know the science
between philosophy and science
VII. Know relevant
VIII. Know relevant
policies of the profession
IX. Know human rights law
X. Know freedom of information
XI. Be alert
XII. Be respectful
appropriately to signals of unease
XIV. Defuse confrontation
XV. Begin by listening
XVI. Don't be in a rush
XVII. Be cautious if
thinking out loud
XVIII. Make notes of every
XIX. Obtain copies of
XX. Get help - early
Networking: doctors and nurses without borders
XXII. Media: look before you leap
XXIII. The Protection of
We are concerned here. . . not with working through
ordinary ethical problems, but with the exercise of freedom of conscience
that may generate an adverse and even hostile reaction from persons in
positions of authority, colleagues, patients, or special interest groups.
Conflicts of conscience can arise for a variety of reasons and in a
variety of circumstances in nursing or medical practice, just as they arise
in other walks of life. We are concerned here, however, not with working
through ordinary ethical problems, but with the exercise of freedom of
conscience that may generate an adverse and even hostile reaction from
persons in positions of authority, colleagues, patients, or special interest
groups. The following recommendations are meant to assist medical and
nursing students faced with this kind of conflict.
Those who take issue with your position will most likely do so because
they are working from beliefs and principles uncritically assimilated from
the dominant social, legal and intellectual culture. You may have difficulty
responding to them if you were raised in a similar environment, even if your
religious or moral upbringing places you, in some sense, 'outside the
culture.' Your religious or moral perspective may be sufficiently different
from your colleagues to generate disagreement about ethics, but your
philosophical or intellectual perspective may be so similar that you find
yourself tongue-tied when attempting to explain your views.
Four points should be kept in mind throughout.
. . . everyone is a believer. Everyone acts and
lives according to some ultimate standard by which he distinguishes right
from wrong. In this respect, an atheist is as much a believer as an
First: in an important sense, everyone is a believer. Everyone acts and
lives according to some ultimate standard by which he distinguishes right
from wrong. In this respect, an atheist is as much a believer as an
observant Jew. To demand that someone surrender his religious or moral
convictions and instead accept 'the ethics of the profession' does not
exclude belief; it suppresses one kind of belief and replaces it with
another. Absent the demonstrable moral superiority of the members of the
profession, there is no valid reason to submit to this kind of coercion. [There
Are No Secular Unbelievers] [The
Illusion of Moral Neutrality - Part IV] [Establishment
Second: the sciences that deal with material reality are not the only
sources of knowledge, and certainly do not produce what is essential for the
realization of human happiness through the correct ordering of society and
human relationships. Love, justice, mercy, solidarity, wisdom and other
virtues will make the most unscientific society a happy one, while the most
scientific society will be rendered miserable by their absence.
Third: conscientious objection is a means by which a practitioner can
preserve his own integrity by refusing to facilitate or participate in an
immoral act. It is not a means to control the conduct of the patient or
convert patients or colleagues to one's views.
Finally: the following recommendations are not exhaustive, and they should
be adapted to your circumstances, experience and personality.
Students in some countries may have to consider what
might be expected of them in relation to capital punishment, torture, or
coercive interrogation of persons in state custody.
As a first step, you must identify practices, procedures, or services
that may be expected of you, but to which you object for reasons of
conscience. The most common controversies centre around issues at the
beginning and end of life: abortion, contraception, euthanasia, assisted
suicide. However, the morality of artificial reproductive technology and
eugenic engineering is sharply contested, and you may also have concerns
about research on human subjects. Students in some countries may have to
consider what might be expected of them in relation to capital punishment,
torture, or coercive interrogation of persons in state custody.
. . .people raised within a religious, moral or
cultural tradition are more likely to live by their beliefs and principles
than to analyse them. As a result, they may find it difficult to explain or
defend them when pressed, even if those principles are solidly grounded in
practical wisdom and tested by centuries of collective experience.
Having identified morally problematic procedures or services, which you
may be able to do with little difficulty, it is not prudent to rest a claim
to conscientious objection upon a generic and undeveloped appeal to
religious belief or freedom of conscience. You must articulate the basis for
your objections. There are three reasons for this.
First: even if the law in your jurisdiction recognizes freedom of
conscience and religion, such freedoms are not unlimited in principle. Those
who want to suppress freedom of conscience among health care workers are
less likely to deny that freedom than to substantially restrict it. Thus,
you must not only be able to identify a religious or moral basis for your
objection; you must be prepared to argue that it is reasonable and possible
to accommodate you.
Second: religious believers may find that nominal co-religionists do not
share their judgement about the moral acceptability of a procedure. This can
make it more difficult to credibly assert, for example, that "Christians do
not do X" or "Muslims do not do Y", especially if the person opposing your
views has some official religious status or authority. Additional
complications arise within a denominational health care institution in this
Third: people raised within a religious, moral or cultural tradition are
more likely to live by their beliefs and principles than to analyse them. As
a result, they may find it difficult to explain or defend them when pressed,
even if those principles are solidly grounded in practical wisdom and tested
by centuries of collective experience. They may also make contradictory or
ill-founded statements when struggling to articulate their views. In
consequence, they can lose credibility with colleagues or persons in
authority, and significantly weaken arguments that might be made later in an
appeal before an academic committee, a disciplinary hearing, or court case.
Carefully consider the religious doctrines or moral principles to which you
adhere to ensure that you understand them correctly, can apply them in
practical situations and can explain them to others. As a conscientious
objector, you must develop your ability to communicate with people who do
not share your views, or who actively oppose them. Listen carefully to
opposing arguments and prepare effective responses.
Conflicts frequently arise with respect to referral
and the provision of some kinds of information, so you must determine, in
advance, how you will approach these issues.
An important reason for reflecting carefully upon how to apply your
religious or moral convictions is that you must determine what kinds of
actions would compromise your personal integrity. Some people consider
themselves morally culpable only if they are direct participants in an
immoral act, and do not object to referring a patient to someone willing to
do what the patient wants. Others believe that it is immoral to facilitate a
wrong by referral or other forms of assistance. [Referral:
A False Compromise] Conflicts frequently arise with respect to referral
and the provision of some kinds of information, so you must determine, in
advance, how you will approach these issues. You must also consider how you
will respond when in doubt about significant facts or moral issues,
particularly when life or health is imminently at risk.
Religious and ethical traditions frequently offer principles or
guidelines to assist with moral reasoning. Be sure that you are aware of
them, and be prepared to look to the insights offered by other traditions to
supplement your own.
Sound moral or ethical reasoning depends upon a
complete and accurate grasp of relevant facts. . . Demonstrate appropriate
academic discipline and intellectual honesty in your adherence to or
rejection of research findings.
Sound moral or ethical reasoning depends upon a complete and accurate
grasp of relevant facts. For example: one cannot discuss the morality of
embryonic stem cell research without a correct understanding of human
embryology, and conscientious objection to euthanasia ought to be informed
by adequate knowledge of palliative care. You may not be able to master all
of the literature on a given subject, but you should take care to inform
yourself fully about critical issues or points of contention. Demonstrate
appropriate academic discipline and intellectual honesty in your adherence
to or rejection of research findings. [Science,
the Formation of Conscience and Moral Decision Making]
Academic discipline requires an ability to distinguish between what lies
within the province of science and what lies elsewhere. "Personhood" can
have distinctive philosophical or legal meanings, but it is not a scientific
concept at all. Whether or not something "ought" to be done is a subject for
philosophy, religion, or ethics - not science. [Scientific
and Philosophical Expertise: An Evaluation of the Arguments on "Personhood"]
. . . you should not tolerate bullying by
professors, preceptors or colleagues who attempt to dismiss your moral
convictions on the specious grounds that they are 'unscientific'; their own
moral convictions are equally unscientific, and cannot be otherwise.
It is quite appropriate to challenge moral reasoning that is based upon
erroneous science. But you should not tolerate bullying by professors,
preceptors or colleagues who attempt to dismiss your moral convictions on
the specious grounds that they are 'unscientific'; their own moral
convictions are equally unscientific, and cannot be otherwise.
Universities ought to have fairly extensive policies on evaluations of
academic progress and of preceptorships. These policies should set out, in
general terms, how the evaluations are to be done and how they may be
appealed. A description of the appeal process ought to include the manner in
which an appeal is to be launched, the stages through which it progresses,
and the times within which each stage must be completed. Ideally, the
policies will also set out the composition of the various committees or
bodies hearing the appeal and the rights of students with respect to
representation at the hearings. You should review these policies and ensure
that you understand them and know how to access them.
Professional colleges and associations have codes of ethics and policies
that touch on issues of concern to conscientious objectors. For example: the
Canadian Medical Association does not require referral for morally
controversial procedures. Obtain copies of these policies and study them.
Pay particular attention to the policies of regulatory bodies like Colleges
of Physicians, which have disciplinary and licensing authority, but do not
ignore the policies of specialist associations that may have considerable
influence in setting 'standards of care.'
You cannot be expected to master human rights
jurisprudence, but you should read the statutes governing human rights law
in your jurisdiction and make copies of relevant sections.
You cannot be expected to master human rights jurisprudence, but you
should read the statutes governing human rights law in your jurisdiction and
make copies of relevant sections. Be aware that statutes are interpreted by
courts in decisions that are reported in "case law," and that a full
understanding of the law requires knowledge of these cases. You are unlikely
to have time for that kind of research. If a question arises about the
application of part of a human rights statute to your case, you might begin
by seeking help from a friend who is studying law. You might also be able to
consult a paralegal service provided by a university law school, unless you
believe that it may be unsympathetic or even hostile. If the issue is
important or complicated, consult a lawyer.
Many jurisdictions now have freedom of information statutes that give
citizens the right to access any information about them held by state or
institutional authorities. Depending upon the wording of a statute, such a
law might be used to force the university to disclose any information it has
in its files concerning you, including 'confidential' internal memos and
e-mails. If there is a freedom of information law in your jurisdiction,
obtain a copy of it and find out whether or not it applies to the
university. You may be able to get this information easily if the university
has a privacy or freedom of information officer responsible for complying
with requests for disclosure.
Having identified your concerns, you must be alert to any suggestion or
inference that someone who can adversely affect your professional or
educational standing has taken unfavourable notice of your views. The first
indication could be as blatant as an expletive-filled remonstrance, or as
subtle as a questioning glance. You must be on the lookout for any sign of
approaching difficulty in order to take all appropriate steps to protect
Some objectors encounter problems primarily because of the way they
communicate with patients, colleagues or others. If it is necessary to
explain your position, do so in a way that refers to your own moral
responsibility, not that of your patient or colleague. Avoid expressions
that impute wrongdoing to others or that might come across as "preaching".
You should not become hypersensitive to what others
might be thinking, since that will only cause needless anxiety. On the other
hand, one should not ignore clear signals that something is amiss.
Conscientious objection is likely to make colleagues who do not share
your views uncomfortable because it implies that what they are doing is
wrong. It is unwise to increase their discomfort by making statements that
will be perceived as questioning their moral judgement, as they are then
likely to become hostile. Take note of their discomfort - ."You seem
troubled/ disturbed/surprised" - and invite dialogue - "Have I offended
This approach expresses concern for the other person and respect for his
sensibilities, while providing an opportunity for discussion.
You should not become hypersensitive to what others might be thinking, since
that will only cause needless anxiety. On the other hand, one should not
ignore clear signals that something is amiss. Your ability to read those
signals will depend upon how well you know the other person and your own
experience. If in doubt, remain silent, but make a note of the incident. If
a problem is developing, your notes will probably make it apparent to you in
. . .don't rush into what might prove to be a
contentious discussion simply because you feel the need to counter an
offensive or ill-timed remark.
In addition to discomfort, you may encounter a belligerent challenge,
contempt or condescension. If you are taken by surprise or find yourself
flustered, no harm is done by admitting the fact and suggesting that you and
your interlocutor should make time for an uninterrupted chat. If it is
possible to make time for it then and there, do so. However, don't rush into
what might prove to be a contentious discussion simply because you feel the
need to counter an offensive or ill-timed remark. You will do yourself and
your colleague a favour by giving yourself even a few minutes to reflect and
The notion of working together with your critic is
important. The goal is authentic and respectful communication, even if it
involves serious argument and fundamental disagreements.
Resist the urge to explain or defend yourself. Instead, ask your
interlocutor to explain his concerns. Listen carefully, and ask questions,
not to challenge his views, but to clarify the issues and identify any
unexamined presuppositions that are governing his approach to them. This
will give you the opportunity to settle some butterflies, organize your own
thoughts and build your confidence. It should also diminish any antagonism
felt by your critic, since he will see that you are listening to him and
taking his concerns seriously. He may even feel that he is making a
significant impact on you.
Nonetheless, the most important reason to begin by listening is that you
cannot respond effectively if you do not know what case you have to answer.
There is no point exasperating a colleague by attempting to argue from
incorrect assumptions about what he knows or believes. Let him tell you.
Identify points of agreement and points of contention, and work together
The notion of working together with your critic is important. The goal is
authentic and respectful communication, even if it involves serious argument
and fundamental disagreements.
If you are uncertain about how to reply to facts or an argument presented
by your critic, you should simply admit it and promise to continue the
discussion after you have had time to think further about it or research the
problem. Offer your critic the same courtesy, unasked for, if need be. There
is no need to resolve everything at once. In fact, it may prove difficult to
resolve even preliminary matters in the first encounter.
When serious discussion generates enthusiasm for enquiry you may find
yourself 'thinking out loud' as you attempt to tease out the strands of your
critic's argument or consider the significance of a fact he raises. When the
issue is conscientious objection, this ordinarily harmless habit should be
avoided, especially in conversation with persons in authority. If you
sincerely say "A" to one person, and, upon reflection, later revise "A" to
"B," you may be accused of duplicity or irrationality, or characterized as
someone who doesn't know what he believes. Better to consider the issue
privately or with the assistance of an ally than to speak to it prematurely.
Do not rely on your memory even in the case of
encounters that you are sure you will never forget. An appeal to an academic
committee may not be heard for months; cross-examination before a court or
human rights tribunal could come two years afterward. You will not
accurately recall what was said unless you make notes of it at the time.
Make detailed notes each time you encounter criticism or questions about
your views, even if the incident seems minor or unimportant. The real
significance of an innocuous question in September may not become apparent
until after a clash in February. You will never regret recording
information, but you will certainly regret not having done so.
Do not rely on your memory even in the case of encounters that you are
sure you will never forget. An appeal to an academic committee may not be
heard for months; cross-examination before a court or human rights tribunal
could come two years afterward. You will not accurately recall what
was said unless you make notes of it at the time. Moreover, if the other
parties to the incident made notes and you did not, it is probable that
their accounts of what took place will be given much greater weight than
If you cannot make detailed notes at the time or immediately afterward,
make what notes you can, and expand them at the first reasonable opportunity
that day. See
Making Notes for a detailed discussion of note taking.
You can use a hand-held tape recorder to make your notes, whether in
short or expanded form. You should then transcribe the notes. Transcription
will put the notes into a form that can conveniently be used by others and
will prevent them from being lost by erasure or damage. However,
transcription is time-consuming, so you should not procrastinate. You will
not want to be struggling to transcribe eight or nine hours of tape while
studying for your final exams and preparing an appeal of your evaluation.
You should initial each page of an evaluation, memo or other document
that refers to your conscientious objection. Initial below the last entry on
each page or section, or strike a line from the last entry to the bottom of
the page or section and initial there. Obtain a copy of the initialled
document. This will prevent it from being changed later.
If university authorities refuse to give you a copy of the document,
advise them that you believe that you are entitled to it because it is your
information. Tell them that you would rather not mobilize the student body
in support of students' right of access to their information, and would like
to avoid a court confrontation to compel its release. This may result in a
hurried conference and the making of "an exception" in your case, especially
if the university policy violates freedom of information laws in your
jurisdiction. If it does not, consult your contacts within the profession.
If your university has a law school you may be able to access some form of
para-legal assistance through senior students there; otherwise, see a
You should seriously consider seeking legal advice
if you encounter significant opposition. A failure in a key preceptorship or
subject may nullify everything else you have accomplished. The harm done by
losing an appeal at the first level may prove very difficult to undo . . .
It is important to connect with like-minded colleagues in the university
so that you can discuss problems as they arise. It is even more important to
remain in contact with sympathetic people already active in your chosen
profession, as their experience and knowledge of its administration will
likely be invaluable if you run into trouble. Seek their advice and
assistance as soon as you encounter any significant criticism. When
approached by a student in difficulty, the Protection of Conscience Project
will immediately facilitate contact between the student and professionals
who are willing to assist.
If you encounter opposition, criticism, unfair evaluations or other forms
of repression from university authorities, professors or preceptors, do
not assume that you will be able to work things through on your own,
especially if you have to launch an academic appeal. You should seriously
consider seeking legal advice if you encounter significant opposition. A
failure in a key preceptorship or subject may nullify everything else you
have accomplished. The harm done by losing an appeal at the first level may
prove very difficult to undo in subsequent appeals or even through civil
Long before a crisis looms you should seek the
fellowship of students and professionals from other religious traditions (or
none) who have a common interest in securing freedom of conscience in health
Anti-religious secularists often try to banish religion from the public
square by claims that religious beliefs are intrinsically divisive and
encourage differences that lead to violence. The example of friendly
collaboration in matters of mutual interest among people of different
faiths, disciplines and backgrounds provides a practical and powerful
counter-witness to such assertions. This is one of the reasons that the
Project Advisory Board consists of scholars from different disciplines
and different faiths, including Judaism, Catholic and Protestant
Christianity, the Latter Day Saints and Islam.
Long before a crisis looms you should seek the fellowship of students and
professionals from other religious traditions (or none) who have a common
interest in securing freedom of conscience in health care. You may be
surprised to find that someone from a completely different faith and culture
is more supportive of your views than a co-religionist who lives down the
If your university has a medical school, it may well have a law school and
departments of philosophy and political science. You may find friends and
supporters in all of these faculties.
Be cautious if you are approached by the media, as
media reports may well complicate resolution of your difficulty. . .
'Advocacy journalism' from any perspective is potentially problematic;
'friendly fire' kills, too.
Be cautious if you are approached by the media, as media reports may well
complicate resolution of your difficulty. The 'friendly' reporter may skewer
you, or his editor may mangle story by cutting or changing it for
publication . More commonly, the media often highlight controversy (conflict
sells) and polarize opinion by simplistic reporting that fails to make
appropriate distinctions or identify important issues. 'Advocacy journalism'
from any perspective is potentially problematic; 'friendly fire' kills, too.
Television and radio interviews present particular problems because a
lengthy interview may yield a five second sound bite unrepresentative of the
discussion. These 'bites' can be sandwiched between other visuals or
commentary to produce unpleasantly surprising results. It is also
extraordinarily difficult to successfully convey a philosophical or moral
argument on television because pictures - the very essence of TV journalism
- are better at communicating emotion than logical thought.
You should not agree to an interview unless you are quite sure how much
of the case you are prepared to discuss. If there are things that you don't
want to talk publicly about, be sure that you can explain the reason(s) for
your reticence to the reporter in advance. For example: you might think it
safe to explain the principled basis for your objections, but not to discuss
what took place between you and your colleague, preceptor or patient because
of a pending review or hearing. If you attempt to pick and choose the
questions you will answer, it is likely to appear that you have something to
hide or are unsure of yourself. Do not answer a question with, "No
comment." If you choose not to answer a question, explain why you cannot
Do not attempt to direct a reporter as to what angle he should take in a
story or what he should write. Never ask a journalist to let you
review his story before publication. Most will refuse, many will have
nothing more to do with you, and not a few will make you the target rather
than the subject of a column or editorial.
Reporters frequently tape record interviews, but are
not obliged to notify you of the fact. Don't ask if you are being recorded
(the question suggests you have something to hide) but assume that any
conversation with a reporter is being taped.
Reporters frequently tape record interviews, but are not obliged to
notify you of the fact. Don't ask if you are being recorded (the question
suggests you have something to hide) but assume that any conversation with a
reporter is being taped. You may record your conversations and interviews
with reporters, but always tell them you are doing so. One journalist
consulted by the Project commented, "Your recording will keep an honest
reporter honest, and scare the dishonest one straight."
If surprised by a call from a reporter, take his name and contact
information and call him back after you have settled your butterflies and
considered your position. If you are not certain that you should speak to
the media, do not do so. An unsolicited request for an interview can be
courteously turned aside with the explanation that you hope to resolve the
problem through the channels open to you, and you don't wish to complicate
matters by speaking publicly. A good reporter will accept this, but will
also try - politely - to get you to say something, perhaps in response to a
hypothetical question. Don't take the bait. Take the reporter's name and
contact information and tell him that you will call should you decide to
speak publicly later on.
If, after an interview, you realize that you have made an error or
believe that you didn't express yourself clearly, call the reporter to
clarify your comments or correct your mistake; better to be considered
sincerely mistaken than carelessly ignorant.
Beware of suggestions that you should 'go public'.
Speaking to the media to garner sympathy or support for your position should
only be attempted after careful consideration and consultation; it is
Beware of suggestions that you should 'go public'. Speaking to the media
to garner sympathy or support for your position should only be attempted
after careful consideration and consultation; it is normally inadvisable.
Fear that you might launch a media initiative may encourage compromise by
your opposition; a failed media initiative will only solidify their
Conscientious objectors usually form a minority within a profession and
the public at large, so even if the media take up the story and people take
notice, it is likely to generate as much opposition as support. Moreover,
opponents of freedom of conscience in health care tend to be well-funded and
well-connected with media, government and the professions. Media attention
may cause them to launch a campaign against you, and you may be hard-pressed
to counter it.
Another point to consider is that the media, politicians and many members
of the professions tend to be dismissive of anything to which a pro-life
label is attached. If your objection concerns a pro-life issue, you will be
able to secure the support of the pro-life community, but that may carry
very little weight with the wider public or those handling your case, and
may actually inflame prejudice against you.
If there is an internal review or appeal process
available to you, that is the first place to make your case. You are likely
to undermine your credibility if you appear to be seeking a verdict through
the media rather than in the proper forum.
If there is an internal review or appeal process available to you, that
is the first place to make your case. You are likely to undermine your
credibility if you appear to be seeking a verdict through the media rather
than in the proper forum. Media reports, especially those that contain
misquotes or other inaccuracies, can come back to haunt you during an
academic appeal or judicial proceeding. You may find yourself being asked to
explain something that you did not say, or (worse) something that you did
say that was reported out of context, or (worst of all) something you regret
having said that was not only accurately reported, but captured on tape.
Despite all of these arguments against 'going public', there are
times when it may be productive to do so. For example: if the university
were to refuse to give you a copy of your evaluation or some similarly
important document, it is likely that most students would support your right
of access, even if they disagreed with your ethical stance. In that case,
however, one would highlight the issue of freedom of information, not
Of course, not all media are hostile or unfair, and sometimes media
attention can favourably influence the course of events. By all means,
collaborate with others to develop a media strategy, but keep it in reserve
until it is clear that it can be implemented safely and effectively. It
might be prudent to first break the story with potentially sympathetic
outlets or reporters who (one hopes) will report it fairly and accurately.
However, once you 'go public,' even with someone you think trustworthy, you
will have no control over how the media handle the story. That is one of the
reasons your opponents may be willing to compromise to avoid public
exposure. They can't control the media, either.
Victim Wordksheet on the Project website can be downloaded or completed
on-line. It is meant to help you to obtain and organize information
pertaining to your case. Completing the survey before you see a lawyer or
other professional will provide you with much of the information he may
require in order to assess your position.
Use the Project website to obtain arguments and information relevant to
your situation. Contact the
Project Administrator if you cannot find what you need, or if you are
encountering coercion or discrimination. Every effort will be made to
provide you with support and assistance. The service is limited, but it is
Even if it had the resources, the Project has no standing to intervene
with university authorities or appear before a tribunal hearing your case,
but it may be possible to prepare a
report on the matter. The report will be given to you, to be used in
accordance with the rules of evidence in your jurisdiction and as you or
your counsel think best. It will not be further disseminated without your
permission. With respect to Project reports, please bear in mind the
- A report is only as good as the information upon which it is based.
- The preparation of a report is a painstaking and time-consuming
process. One such report runs to 21 single spaced pages, with an
additional 34 pages of appendices and 126 end notes. If a report is
needed, all available information and documents should be forwarded to
the Project as soon as possible.
- A Project report is not polemical whitewash. If it is to stand
scrutiny, it must be based upon the evidence submitted. It may,
therefore, include comments unfavourable to the objector.