John K. Alexander
- When we seek professional help (service) we have the expectation that the
professionals that we deal with will provide us with competent service. This
is especially true when the services we seek are a normal part of the
services that the professionals would be called upon to provide in the
normal course of their professional lives within the specific practice
with which they are associated. However, there have been instances where
professionals have refused to provide service in these types of
circumstances. In these instances professionals sometimes argue that to
provide the requested service would be in violation of their personal
moral standards and beliefs and that they ought not to be required to act
against what these standards and beliefs require them to do. . .
Y. Michael Barilan
- Abstract: Over and above fairness, the concept of
justice presupposes that in any community no one member's wellbeing or
life plan is inexorably dependent on the consumption or exploitation of
other members. Renunciation of such use of others constitutes moral
sociability, without which moral considerability is useless and possibly
meaningless. To know if a creature is morally sociable, we must know it in
its community; we must know its ecological profile, its species. Justice
can be blind to species no more than to circumstance. Speciesism, the
recognition of rights on the basis of group membership rather than solely on
the basis of moral considerations at the level of the individual
creature, embodies this assertion but is often described as a variant of
Nazi racism. I consider this description and find it unwarranted, most
obviously because Nazi racism extolled the stronger and the abuser and
condemned the weaker and the abused, be they species or individuals,
humans or animals. To the contrary, I present an argument for speciesism as
a precondition to justice.
Tom L. Beauchamp
- Rebecca Kukla's engaging article is a theoretically rich and
practically wise addition to the literature on autonomy in bioethics. She
criticizes what she calls the "one clearly dominant account of
autonomy." This "received view" depicts autonomy as self-determination
in decision-making through adequate understanding, deliberation, and
freedom from controlling interferences;in effect, autonomy is analyzed as
informed consent. . . .
Rebecca Kukla's recent article is an ambitious - and vitally needed
- attempt to advance current thinking on what patient "autonomy" in
medical care would involve if it existed. Her alternative framework
derives from the assumption that patients' medical decisions are
formed within broader, ongoing social activities, both health-related
and not. She's certainly correct to assert that researchers and
theorists working on the subject have focused too narrowly on informed
consent and that much of what we term"health care" does not involve any
decision- making. . .
Castro O, Lombardo FA, Gordeuk VR.
The celestial fire of conscience.
(Letter) N Engl J Med. 2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID:
Oswaldo Castro, Frederic A. Lombardo, Victor R. Gordeuk
- Charo links the "abortion wars" to the refusal by medical personnel to
collaborate in certain acts. It is not accurate, however, to assert
that medical care or services are being refused. Real medical care and
services always respect human life. No one should be forced to
collaborate in abortion (even when it is achieved through the prevention
of implantation), lethal research on embryos, euthanasia, or assisted
suicide. . .
R. Alta Charo
- Apparently heeding George Washington's call to "labor to keep alive in
your breast that little spark of celestial fire called conscience,"
physicians, nurses, and pharmacists are increasingly claiming a right to
the autonomy not only to refuse to provide services they find
objectionable, but even to refuse to refer patients to another provider
and, more recently, to inform them of the existence of legal options for
care. . .
Charo, RA. The celestial fire of conscience. N Engl J Med.
2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180276.
R. Alta Charo
- With regard to Dr. Lee's comment that the proposed Wisconsin
legislation does not eliminate a health care provider's duty to
provide a referral after refusing to perform a service, I would note that
Assembly Bill 207 (passed June 14, 2005, and now pending in the state
senate) specifically permits health care providers' refusals to
"participate in" services they find personally objectionable, with
"participate in" specifically defined in section 2(c) as "to perform;
practice; engage in; assist in; recommend; counsel in favor of; make
referrals for; prescribe, dispense or administer drugs" (emphasis added).
Stephen Joel Coons
- There has been substantial local and national media coverage of issues
surrounding a pharmacist's right to refuse to dispense prescription
medications that he or she deems objectionable based on personal moral
and/or religions beliefs, t.z Much of this attention has been prompted by
an increasing number of cases in which pharmacists are refusing to
dispense hormonal contraceptives, including, but not limited to, emergency
contraception. In respome, elected representatives at the state and
federal levels have been actively engaged in introducing, enacting, or
vetoing measures that address this issue from one side or the other; some of
these measures are aimed at protecting patients and others are aimed at
- Abstract: There seem to be two clearly-defined camps in
the debate over the problem of moral expertise. On the one hand are the
''Professionals'', who reject the possibility entirely, usually because of
the intractable diversity of ethical beliefs. On the other hand are the
''Ethicists'', who criticise the Professionals for merely stipulating
science as the most appropriate paradigm for discussions of expertise. While
the subject matter and methodology of good ethical thinking is certainly
different from that of good clinical thinking, they argue, this is no
reason for rejecting the possibility of a distinctive kind of expertise in
ethics, usually based on the idea of good justification. I want to argue
that both are incorrect, partly because of the reasons given by one group
against the other, but more importantly because both neglect what is most
distinctive about ethics: that it is personal in a very specific way,
without collapsing into relativism.
The celestial fire of conscience. N Engl J Med. 2005
Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180277.
- Kudos to Charo for reminding us that doctors, hospitals, pharmacists,
and pharmacies enjoy monopolies much like those of public utilities
- and have commensurate service obligations. Imagine if electric
utilities refused service to anyone conducting stem-cell research. At
least the victims would know that they had been cut off.
- Laws, regulations, and ethical codes often address conflicts between
personal beliefs and workplace demands. Such conflicts are common in
the health setting, where work is intimately connected to matters of life
and death, privacy, and dignity. In the latest conflict attracting
attention, pharmacists have expressed moral beliefs that interfere
with women's reproductive health needs. Journalists and others have
reported cases of individual pharmacists refusing to fill prescriptions
for emergency contraceptives. Because emergency contraception can act to
block implantation of a fertilized egg, people who believe in protection
of human life after conception find it morally objectionable. . .
Elizabeth Fenton, Loren Lomasky
- Citing grounds of conscience, pharmacists are increasingly refusing to
fill prescriptions for emergency contraception, or the "morningafter
pill." Whether correctly or not, these pharmacists believe that emergency
contraception either constitutes the destruction of postconception human
life, or poses a significant risk of such destruction. We argue that the
liberty of conscientious refusal grounds a strong moral claim, one that
cannot be defeated solely by consideration of the interests of those
seeking medication. We examine, and find lacking, five arguments for
requiring pharmacists to fill prescriptions. However, we argue that in
their professional context, pharmacists benefit from liberty restrictions
on those seeking medication. What would otherwise amount to very strong
claims can be defeated if they rest on some prior restriction of the
liberty of others. We conclude that the issue of what policy should
require pharmacists to do must be settled by way of a theory of second
best. Asking "What is second best?" rather than "What is best?" offers a
way to navigate the liberty restrictions that may be fixed obstacles to
Greenberger MD, Vogelstein R. Public health.
Pharmacist refusals: a
threat to women's health. Science. 2005 Jun 10;308(5728):1557-8. PubMed
Marcia Greenberger, Rachel Vogelstein
Pharmacist refusals to fill prescriptions for birth control based on
personal beliefs have been increasingly reported around the world. In
the United States, reports of pharmacist refusals have surfaced in
over a dozen states. These refusals have occurred at major drugstore
chains like CVS and Walgreens and have affected everyone from rape
survivors in search of emergency contraception to married mothers
needing birth control pills. Pharmacists who refuse to dispense also
often have refused to transfer a woman's prescription to another
pharmacist or to refer her to another pharmacy. Other pharmacists have
confiscated prescriptions, misled women about availability of drugs,
lectured women about morality, or delayed access to drugs until they
are no longer effective.
Hurst SA, Hull SC, DuVal G, Danis M.
How physicians face ethical
difficulties: a qualitative analysis. J Med Ethics. 2005
Jan;31(1):7-14. PubMed PMID: 15634746; PubMed Central PMCID: PMC1734016.
S. A. Hurst, S. C. Hull, G. DuVal, M. Danis
- Background: Physicians face ethical difficulties daily, yet they seek
ethics consultation infrequently. To date, no systematic data have been
collected on the strategies they use to resolve such difficulties when
they do so without the help of ethics consultation. Thus, our understanding
of ethical decision making in day to day medical practice is poor. We
report findings from the qualitative analysis of 310 ethically difficult
situations described to us by physicians who encountered them in their
practice. When facing such situations, the physicians sought to avoid
conflict, obtain assistance, and protect the integrity of their
conscience and reputation, as well as the integrity of the group of people
who participated in the decisions. These goals could conflict with each
other, or with ethical goals, in problematic ways. Being aware of these
potentially conflicting goals may help physicians to resolve ethical
difficulties more effectively. This awareness should also contribute to
informing the practice of ethics consultation.
Objective: To identify strategies used by physicians in dealing with
ethical difficulties in their practice.
Design, setting, and participants: National survey of internists,
oncologists, and intensive care specialists by computer assisted
telephone interviews (n = 344, response rate = 64%). As part of this survey,
we asked physicians to tell us about a recent ethical dilemma they had
encountered in their medical practice. Transcripts of their open-ended
responses were analysed using coding and analytical elements of the
grounded theory approach. Main measurements: Strategies and approaches
reported by respondents as part of their account of a recent ethical
difficulty they had encountered in their practice.
Results: When faced with ethical difficulties, the physicians avoided
conflict and looked for assistance, which contributed to protecting, or
attempting to protect, the integrity of their conscience and reputation,
as well as the integrity of the group of people who participated in the
decisions. These efforts sometimes reinforced ethical goals, such as
following patients' wishes or their best interests, but they sometimes
competed with them. The goals of avoiding conflict, obtaining assistance,
and protecting the respondent's integrity and that of the group of
decision makers could also compete with each other.
Conclusion: In resolving ethical difficulties in medical practice,
internists entertained competing goals that they did not always
successfully achieve. Additionally, the means employed were not always the
most likely to achieve those aims. Understanding these aspects of ethical
decision making in medical practice is important both for physicians
themselves as they struggle with ethical difficulties and for the ethics
consultants who wish to help them in this process.
Katherine A. James
- Introduction: In Texas, a pharmacist refused to fill
a rape victim's emergency contraceptive prescription.2 A Wisconsin
student encountered a pharmacist who refused to fill her birth control
prescription and refused to transfer it to another pharmacist. 3 A
pharmacist told a woman in Minnesota seeking birth control to return in a
few days to have a different pharmacist assist her.4 These are just a few
of the reported incidents of pharmacists refusing to fill contraceptive
prescriptions because of the pharmacists' own personal beliefs.5 These
beliefs, however, conflict with the customers' right to take the
prescribed medication. . .
- The Criminal Code of Canada prohibits assisted suicide. . .It appears the
Parliament has once again decided to consider the issue: this time in the
form of Bill C-407 – An Act to amend the Criminal Code (right to die with
dignity). The purpose of the Bill is to amend the Criminal Code so as to
allow assisted suicide under certain specified conditions. . .If previous
experience is anything to go by, Bill C-407 will not be passed into law. The
political forces that are arrayed against it are far too well organized, far
too powerful and far too vociferous. However, that may not be a bad thing –
because the proposed law itself has fundamental flaws and is seriously
incomplete. . . the Bill is a partial measure at best. It deals only with
assisted suicide, not euthanasia. It would not help those who, although
competent, could not perform the final act themselves because they are
disabled. . . What follows is an attempt to correct some of these
shortcomings. . . .
- The standard bioethics account is that respecting patient autonomy means
ensuring that patients make their own decisions, and that requires that
they give informed consent. In fact, respecting autonomy often has more
to do with the overall shape and meaning of their health care regimes.
Ideally, patients will sometimes take control of their health care but
sometimes defer to medical authority. The physician's task is, in part,
to inculcate patients into the appropriate good health care regimes
- My differences with Hilde Lindemann and Carole Browner are
terminological rather than substantive. Lindemann rightly suggests
that one could reclaim the term "self-determination" and give it a
richer, less individualist reading, just as I have tried to do for the
term "autonomy." However, in my article I simply stipulated that by
self-determination I meant something akin to what she calls
self-sufficiency - that is, being an independent, rational source and
center of one's own decisions and actions.
The celestial fire of conscience. N Engl J Med. 2005 Sep
22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16177261.
- With regard to the Perspective article by Charo on conscience clauses,
I am disappointed by the treatment of a very serious topic in
medicine. The debate over conscience is an important one for both
providers and patients. Charo offers distortions of the proposed
Wisconsin law, as well as a very biased approach. Even the title frames
the discussion in terms of the refusal of care. . .
- In "Conscientious Autonomy: Displacing Decisions in Health Care"
(HCR, Mar-Apr 2005), Rebecca Kukla argues persuasively that it's a
mistake to equate autonomy with the ability to make self-originating,
informed, punctate decisions. Often, she points out, we defer to those
who can reasonably be assumed to have more authoritative knowledge
than we do regarding some particular practice. . .
Henri R. Manasse Jr.
- The recent deluge of media attention about conscientious objection and
the role of the pharmacist in helping patients obtain medications that
some consider morally objectionable (e.g., the "morning-after pill")
presents an opportunity to f ind common ground in what has become a
highly charged public debate. State legislators and members of the U.S.
Congress have even jumped into the fray with quickly drafted legislation
that fails to address the heart of the problem (1).
- In her otherwise excellent paper, Rebecca Kukla makes two
problematic points about trust. First, she argues that trusting health
care providers enough to defer to them does not undermine patient
autonomy and can even enhance it, so long as patients conscientiously
assess how trustworthy their providers are. And second, she claims
that patients need to trust that they are competent to critique their
willingness to defer to providers, and also be able to conscientiously
evaluate this selftrust. Both points require qualification.
The celestial fire of conscience. N Engl J Med.
2005 Sep 22;353(12):1301-2; author reply 1301-2. PubMed PMID: 16180276.
- It is curious that pharmacists might refuse to fill a prescription.
Must all the prescriptions they fill result from morally acceptable
diagnoses? The Health Insurance Portability and Accountability Act of
1996 (HIPAA) does not allow breaches in confidentiality about diagnoses
and therapies so that strangers can make individual judgments about
whether to cooperate in treating a patient. . .
Jessica J. Nelson
- With ever-increasing advancements in technology comes everincreasing
controversy. As society in America continues to legalize medical products
and procedures that conflict with many religious traditions, medical
professionals frequently have to face the ethical dilemma of whether to
perform services that they find morally repugnant. These professionals
are often faced with a choice between following their consciences or
losing their jobs. In this time of questionable medical advancements, the
need for conscience clauses has never been greater. If society is
prepared to legalize controversial health care products and procedures,
it must also work to protect those who do not agree with them. This
paper will address the need for federal and state lawmakers to create
conscience clauses in order to protect medical professionals,
specifically pharmacists, from being forced to violate their consciences
in the workplace.
Venke Sørlie, Annica Kihlgren and Mona Kihlgren
- Five registered nurses were interviewed as part of a comprehensive
investigation by five researchers into the narratives of five enrolled
nurses (study 1, published in Nursing Ethics 2004), five registered
nurses (study 2) and 10 patients (study 3) describing their experiences
in an acute care ward at one university hospital in Sweden. The project was
developed at the Centre for Nursing Science at Örebro University
Hospital. The ward in question was opened in 1997 and provides care for a
period of up to three days, during which time a decision has to be made
regarding further care elsewhere or a return home. The registered nurses
were interviewed concerning their experience of being in ethically
difficult care situations in their work. Interpretation of the theme
'ethical problems' was left to the interviewees to reflect upon. A
phenomenological hermeneutic method (inspired by the French philosopher
Paul Ricoeur) was used in all three studies. The most prominent feature
revealed was the enormous responsibility present. When discussing their
responsibility, their working environment and their own reactions such as
stress and conscience, the registered nurses focused on the patients and the
possible negative consequences for them, and showed what was at stake for
the patients themselves. The nurses demonstrated both directly and
indirectly what they consider to be good nursing practices. They
therefore demand very high standards of themselves in their interactions
with their patients. They create demands on themselves that they believe
to be identical to those expected by patients.
- Executive Summary. This essay examines (1) the underlying philosophical
considerations when patients or decision makers request "inappropriate
treatment"; (2) questions to consider in determining if the treatment
sought would be ineffective, or, in the words of Weijer et al., effective
toward a controversial end; and (3) practical ways to resolve such
Teliska H. "Recent Development, Obstacles to
Access: How Pharmacist Refusal Clauses Undermine the Basic Health
Care Needs of Rural and Low-Income Women." 20 Berkeley J. Gender L. &
Just. 229, 231 (2005)
- The professional dilemma becomes how to maintain adherence to
personal mores and conscience and at the same time carry out the
duty to the patient without the appearance of abandonment . . .
Without conscience. N Engl J Med. 2005 Apr
14;352(15):1511-3. PubMed PMID: 15829530.
- This is one of those stories that invite fear. Now we know. During the
period of the past century that I call Night, medicine was practiced in
certain places not to heal but to harm, not to fight off death but to
serve it. In the conflict between Good and Evil during the Second
World War, the infamous Nazi doctors played a crucial role. They preceded
the torturers and assassins in the science of organized cruelty that
we call the Holocaust. There is a Talmudic adage, quite disturbing, that
applies to them: Tov shebarofim le-gehinom - "The best
doctors are destined for hell." The Nazi doctors made hell. . .