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Protection of Conscience Project

Service, not Servitude


Burke GF. The conscience of the physician. Ethics Medics. 2004 Jan;29(1):2-3. PubMed PMID: 15828146.

Greg F. Burke

Cantor J, Baum K. The Limits of Conscientious Objection - May Pharmacists Refuse to Fill Prescriptions for Emergency Contraception? N Engl J Med. 2004 Nov 4;351(19):2008-12. PMID: 15525728 [Project response]

Julie D. Cantor, Ken Baum

  • Health policy decisions are often controversial, and the recent determination by the Food and Drug Administration (FDA) not to grant over-the-counter status to the emergency contraceptive Plan B was no exception. Some physicians decried the decision as a troubling clash of science, politics, and morality. Other practitioners, citing safety, heralded the agency's prudence. Public sentiment mirrored both views. Regardless, the decision preserved a major barrier to the acquisition of emergency contraception - the need to obtain and fill a prescription within a narrow window of efficacy.

Charatan F. US doctors debate refusing treatment to malpractice lawyers. BMJ.2004 Jun 26;328(7455):1518. PMID: 15217867

  • Animosity between doctors and medical malpractice lawyers has reached such a pitch in the United States that the American Medical Association last week debated a motion proposing that doctors should refuse medical treatment to such lawyers, their families, and employees except in emergencies. Although the motion, brought by Dr Chris Hawk, a surgeon from South Carolina, was lost, some doctors felt the fact that it was proposed at all shows how bad relations between the professions have become. Doctors are angry, among other things, at the effect that malpractice awards are having on their insurance premiums. . .

Davis, JK. Conscientious Refusal and a Doctor's Right to Quit. Journal of Medicine and Philosophy 2004, Vol. 29, No. 1, pp. 75-91.

John K. Davis

  • Patients sometimes request procedures their doctors find morally objectionable. Do doctors have a right of conscientious refusal? I argue that conscientious refusal is justified only if the doctor's refusal does not make the patient worse off than she would have been had she gone to another doctor in the first place. From this approach I derive conclusions about the duty to refer and facilitate transfer, whether doctors may provide 'moral counseling,' whether doctors are obligated to provide objectionable procedures when no other doctor is available, why the moral consensus among doctors seems relevant even though it does not determine whether something is morally acceptable, and whether doctors should stay out of fields whose standard procedures they find morally unacceptable.

Dudzinski DM. Integrity in the relationship between medical ethics and professionalism. Am J Bioeth. 2004 Spring;4(2):26-7. PMID: 15186683

Denise M. Dudzinski

Delese Wear and Mark G. Kuczewski's criticisms (2004) of the professionalism movement could be recast as the "potential dangers of renam(ing) what has been called medical ethics as professionalism." I discuss two dangers of categorizing medical ethics as a subset of professionalism, both of which are congruous with Wear and Kuczewski's arguments. First, ethical principles and ideals may be concretized to meet dominant goals and interests of a privileged profession. Without more critical reflection on the implicit values of medicine, the profession risks marginalizing vulnerable patients, minority and underrepresented students and physicians, and women. Second, complex virtues such as integrity might be oversimpliªed in the attempt to better measure outcomes.

Faunce T, Bolsin S, Chan WP. Supporting whistleblowers in academic medicine: training and respecting the courage of professional conscience. J Med Ethics. 2004 Feb;30(1):40-3. PubMed PMID: 14872070; PubMed Central PMCID: PMC1757114.

T Faunce, S Bolsin, W-P Chan

  • Conflicts between the ethical values of an organisation and the ethical values of the employees of that organisation can often lead to conflict. When the ethical values of the employee are considerably higher than those of the organisation the potential for catastrophic results is enormous. In recent years several high profile cases have exposed organisations with ethical weaknesses. Academic medical institutions have exhibited such weaknesses and when exposed their employees have almost invariably been vindicated by objective inquiry. The mechanisms that work to produce such low ethical standards in what should be exemplary organisations are well documented and have been highlighted recently. The contribution of elements of medical training in eroding ethical standards of medical students have also been emphasised recently and strategies proposed to reduce or reverse this process. The ability to rapidly change the ethical and professional culture of graduate medical trainees may help to deal with some of the perceived problems of declining ethical standards in academic medicine.

Fogel SB, Rivera LA. Saving Roe is not enough: when religion controls healthcare. Fordham Urban Law J. 2004 Mar;31(3):725-49. PubMed PMID: 16700119.

Susan Berke Fogel, Lourdes A. Riveray

  • This article advocates for legislative action against the "religious exemptions" or "conscience clauses" used by religiously-affiliated healthcare facilities, particular in the context of refusing abortion, sterilization, and other reproductive health services. Among other recommendations, the authors call for religious exemptions on the individual rather than institutional level; that the religious exemption be disallowed in rural areas or situations where reasonable alternatives are unavailable; and a requirement that complete, medically accurate information be made available regardless of a religious exemption.

Furton EJ. Vaccines and the right of conscience. Natl Cathol Bioeth Q. 2004 Spring;4(1):53-62. PubMed PMID: 15192850.

Edward J. Furton

  • As a father of five, I have been confronted with the question of whether to vaccinate my children against rubella ("German measles"). As many now know, this vaccine is currently produced from a cell line that had its origin in abortion.1 Two other vaccines are similarly implicated in the tragedy of abortion: the hepatitis A and the new varicella ("chicken pox") vaccines. As unfortunate as these facts are, an analysis of the problem, using traditional Catholic moral principles, does not seem to indicate that there is any obligation on the part of parents to avoid the use of these products. For my own part, therefore, I have not hesitated to have my children protected against these diseases. . .

Gordon M.  Medical professionalism and conscientious objection: are the two compatible? JR Coll Physicians Edinb 2004; 34:296-300

M. Gordon

  • Abstract: A growing concern exists about the tensions that may be found between medical professionalism and the concept of conscientious objection, on the part of physicians and other healthcare professionals, regarding healthcare decisions made by patients or their surrogates. This tension reflects the concept of what it means to be a healthcare professional in contrast to one's strongly held personal or religious ethical convictions. The major concerns revolve around issues at the beginning or at the end of life. These issues must be addressed to avoid serious conflicts with those for whom healthcare professionals have a duty to serve.

Hackler C. Conscientious objection to an opt-in system. Am J Bioeth. 2004 Fall;4(4):25-6; discussion W35-7. PubMed PMID: 16192193.

Chris Hackler

  • David Steinberg (2004) makes a strong case for an "optin" system to increase the supply of transplantable organs. The incentive to receive preference in organ allocation by agreeing to be a donor oneself would surely motivate more people to donate. While the requirement to donate may be perceived as mildly coercive, it seems more like a little nudge to go ahead and do what one clearly ought to do. . .

Kramlich M. The abortion debate thirty years later: from choice to coercion. Fordham Urban Law J. 2004 Mar;31(3):783-804. PubMed PMID: 16700122.

Maureen Kramlich

  • For more than thirty years, supporters of legalized abortion have publicly advocated for the practice as a matter of "choice."' Initially, these advocates argued for a "right to choose" to be free from governmental interference in the decision to abort. In 1971, Sarah Weddington, who represented Jane Roe2 in the case of Roe v. Wade,3 argued before the United States Supreme Court for a "liberty from being forced to continue the unwanted pregnancy ' She argued before the Court for a negative right, for a restraint on governmental interference in the abortion decision, not for a positive right of access or governmental entitlement to abortion. But today, advocates of legalized abortion argue for governmental facilitation of abortion and are attempting to shift the debate in the public forum from "choice" to "access," a state of affairs that implies "coercion" of those health care providers who disagree. . .

Kramlich M. Coercing conscience: the effort to mandate abortion as a standard of care. Natl Cathol Bioeth Q. 2004 Spring;4(1):29-40. PubMed PMID: 15192848.


Latkovic MS. Pro-life nurses and cooperation in abortion: ordinary care or extraordinary intervention? Natl Cathol Bioeth Q. 2004 Spring;4(1):89-102. PubMed
PMID: 15192853.


Marek, M. J. Nurses' Attitudes Toward Pregnancy Termination in the Labor and Delivery Setting. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 33: 472-479. doi: 10.1177/0884217504266912. (2004)

Marla J. Marek

  • Objective: To examine nurses' attitudes toward pregnancy termination in the labor and delivery setting and the frequency of nurse refusal to care for patients undergoing pregnancy termination.

Design: Nonexperimental, descriptive study. Setting: Six central and northern California hospitals, including Level 1, 2, and 3 facilities. Participants: Seventy-five labor and delivery registered nurses.

Method: Anonymous survey with visual analog scales.

Results: Ninety-five percent of the nurses indicated they would agree to care for patients terminating a pregnancy because of fetal demise, 77% would care for patients terminating a fetus with anomalies that were incompatible with life, and 37% would care for patients terminating for serious but nonlethal anomalies, with a significant drop in agreement as gestation advanced. Few nurses would agree to care for patients undergoing termination for sex selection, selective reduction, or personal reasons. Nurses both accepting and refusing patient care assignments were criticized by coworkers.

Conclusion: Clear guidelines should be established on how to handle nurse refusal to care for patients terminating pregnancy in advance. Open discussions should be encouraged between staff and management to minimize criticism.

McCullough LB. The nature and limits of the physician's professional responsibilities: surgical ethics, matters of conscience, and managed care. J Med Philos. 2004 Feb;29(1):3-9. PubMed PMID: 15449810.

Laurence B. McCullough

  • The nature and limits of the physician's professional responsibilities constitute core topics in clinical ethics. These responsibilities originate in the physician's professional role, which was first examined in the modern English-language literature of medical ethics by two eighteenthcentury British physician-ethicists, John Gregory and Thomas Percival. The papers in this annual clinical ethics number of the Journal explore the physician's professional responsibilities in the areas of surgical ethics, matters of conscience, and managed care.

Murphy S. Access to emergency contraception. J Obstet Gynaecol Can. 2004 Aug;26(8):705-6; author reply 706-7. PubMed PMID: 15452936.

Sean Murphy

  • Rebecca J. Cook and Bernard M. Dickens state, "Physicians who feel entitled to subordinate their patient's desire for well-being to the service of their own personal morality or conscience should not practise clinical medicine. " (Emphasis added).  The statement is unsupported by their own legal references, and it has little to recommend it as an ordering principle in the practice of medicine. . .

Nikas NT. Law and public policy to protect health-care rights of conscience. Natl Cathol Bioeth Q. 2004 Spring;4(1):41-52. PubMed PMID: 15192849.

Nikolas T. Nikas

Sonfield A.  New Refusal Clauses Shatter Balance Between Provider "Conscience," Patient Needs. 7 Guttmacher Rep. On Pub. Pol'y. 1, 2-3 (2004)

Adam Sonfield

  • A series of attention-grabbing lawsuits and a crop of new legislation have spotlighted a long-gathering movement to vastly expand the scope of policies allowing health care providers, institutions and payers to refuse to participate in sexual and reproductive health services by claiming a moral or religious objection. In some cases, these radical new policies are intentionally designed to undermine, if not actually eliminate, the ability of governments at all levels, and even private businesses, to balance providers' "conscience" rights with the ability of patients to exercise their own conscience and gain access to health care services that they want and need. . .

Sørlie V, Kihlgren AL, Kihlgren M. Meeting ethical challenges in acute care work as narrated by enrolled nurses. Nurs Ethics. 2004 Mar;11(2):179-88. PubMed PMID: 15030025.

Venke Sørlie, Annica Larsson Kihlgren, Mona Kihlgren

  • Five enrolled nures (ENs) were interviewed as part of a comprehensive investigation into the narratives of registered nuress, ENs and patients about their experiences in an acute care ward. The ward opened in 1997 and provides patient care for a period of up to three days, during which time a decision has to be made regarding further care ebewhere or a return home. The ENs were interviewed concerning their experience of being in ethically difficult care situations and of acute care work. The method of phenomenological - hermeneutic interpretation inspired by the French philosopher Paul Ricoeur was used. The most prominent feature was the focus on relationships, as expressed in concern for society's and administrators' responsibility for health care and the care of older people Other themes focus on how nurse managers respond to the ENs' work as well as their relationship with fellow EN s, in both work situations and shared social and sports activities. Their reflections seem to show an expectation of care as expressed in their lived experiences and their desire for a particular level and qualitv of care for their own family members. A lack of time could lead to a bad conscience over the 'little bit extra' being omitted. This lack of time could also lead to tiredness and even burnout, but the system did not allow for more time.

Tanne JH. "Conscience" clauses allow US corporate providers to refuse care. BMJ. 2004 Aug 28;329(7464):476. PubMed PMID: 15331464; PubMed Central PMCID:

Janice Hopkins Tanne

  • "Refusal clauses" and "conscience exceptions," which allow US doctors, nurses, and healthcare workers to refuse to provide certain types of health care to patients, are being extended to hospitals, insurance companies, pharmacies, and managed care companies.  New legislation may upset the balance between providers who refuse to provide care to which they have ethical objections and patients' ability to get the care they want and need. . .


Veatch RM. Abandon the dead donor rule or change the definition of death? Kennedy Inst Ethics J. 2004 Sep;14(3):261-76. PubMed PMID: 15497226.

Robert M. Veatch

  • Abstract:  Research by Siminoff and colleagues reveals that many lay people in Ohio classify legally living persons in irreversible coma or persistent vegetative state (PVS) as dead and that additional respondents, although classifying such patients as living, would be willing to procure organs from them. This paper analyzes possible implications of these findings for public policy. A majority would procure organs from those in irreversible coma or in PVS. Two strategies for legitimizing such procurement are suggested. One strategy would be to make exceptions to the dead donor rule permitting procurement from those in PVS or at least those who are in irreversible coma while continuing to classify them as living. Another strategy would be to further amend the definition of death to classify one or both groups as deceased, thus permitting procurement without violation of the dead donor rule. Permitting exceptions to the dead donor rule would require substantial changes in law - such as authorizing procuring surgeons to end the lives of patients by means of organ procurement - and would weaken societal prohibitions on killing. The paper suggests that it would be easier and less controversial to further amend the definition of death to classify those in irreversible coma and PVS as dead. Incorporation of a conscience clause to permit those whose religious or philosophical convictions support whole-brain or cardiac-based death pronouncement would avoid violating their beliefs while causing no more than minimal social problems. The paper questions whether those who would support an exception to the dead donor rule in these cases and those would support a further amendment to the definition of death could reach agreement to adopt a public policy permitting organ procurement of those in irreversible coma or PVS when proper consent is obtained.

Yavarone M. Do anovulants and IUDs kill early human embryos? A question of conscience. Natl Cathol Bioeth Q. 2004 Spring;4(1):63-70. PubMed PMID: 15192851.

Mark Yavarone

Zimmerman A. Pro-life nurses and abortion. Natl Cathol Bioeth Q. 2004 Winter;4(4):665-7. PubMed PMID: 15658023.


Zimmerman RK. Ethical analyses of vaccines grown in human cell strains derived from abortion: arguments and Internet search. Vaccine. 2004 Oct 22;22(31-32):4238-44. PubMed PMID: 15474714.

Richard Kent

  • Abstract: The fact that certain vaccines are grown in cell strains derived decades ago from an aborted fetus is a concern for some. To understand such concerns, a standardized search identified internet sites discussing vaccines and abortion. Ethical concerns raised include autonomy, conscience, coherence, and immoral material complicity. Two strategies to analyse moral complicity show that vaccination is ethical: the abortions were past events separated in time, agency, and purpose from vaccine production. Rubella disease during pregnancy results in many miscarriages and malformations. Altruism, the burden of rubella disease, and protection by herd immunity argue for widespread vaccination although autonomous decisions and personal conscience should be respected.