Anderson RM, Bishop LJ, Darragh M, Gray HH, Nolen AL, Poland
Pharmacists and Conscientious Objection (Scope Note 2006).
Kennedy Inst Ethics J. 2006 Dec;16(4):379-96. PubMed PMID: 17847603.
Richard M. Anderson, Laura Jane Bishop, Martina Darragh, Harriet Hutson
- In March 2005, a Wisconsin pharmacist's act of conscience garnered
headlines across the United States. After a married woman with four
children submitted a prescription for the morning-after pill, the
pharmacist, Neil Noesen, not only refused to fill it, but also refused to
transfer the prescription to another pharmacist or to return the
prescription to the customer. As more such incidents occurred, many
states ". . . decided to consider and enact laws setting the bounds of
pharmacists' and other health care workers' professional obligations"
(III, Grady 2006, p. 327). Discussions of objector legislation, also
referred to as "conscience clauses," "refusal clauses," and "abandonment
laws" (III, Appel 2005, p. 279), are not limited to professional ethics,
but also draw from philosophical, theological, and legal perspectives.
The purpose of this Scope Note is to present a wide variety of viewpoints
on the health provider's right to conscience.
Armand Matheny Antommaria
- Abstract: The film "Who Should Survive?: One of the Choices on Our
Conscience" contains a dramatization of the death of an infant with Down
syndrome as the result of the parents' decision not to have a congenital
intestinal obstruction surgically corrected. The dramatization was based
on two similar cases at The Johns Hopkins Hospital and was financed by
the Joseph P. Kennedy, Jr., Foundation. When "Who Should Survive?" was
exhibited in 1971, the public reaction was generally critical of the
parents' decision and the physicians' inaction. Although technological
developments in medicine were a necessary condition for the production of
this film and its unanticipated reception, they were not a sufficient
condition. The proximate cause was a changed understanding of the
capabilities of individuals with Down syndrome. Part of the impetus for
this change was data showing the adverse effects of institutionalization
on normal children.
Jacob M. Appel
- One of the most sacrosanct principles of medical practice in the
United States is that physicians have a right to choose their own
patients as long as the patient is not in a medical emergency. During the
1980s, a minority of health care professionals invoked this prerogative
in refusing to treat AIDS patients. More recently, doctors incensed
over malpractice premiums have refused to care for lawyers and their
family members. However, this sort of physician autonomy is not
without certain limits-most notably the restrictions found in various federal and
state civil rights statutes. No physician or hospital receiving
government funding, including Medicare and Medicaid, may discriminate
against potential patients on the basis of race, color, religion, or
national origin, and many states have expanded these protections to cover
gender and sexual orientation. What remains unclear is whether
physicians with bona fide religious objections to treating certain
patients are exempt from these proscriptions. A California case,
currently on appeal before a state court, may soon decide the matter. . .
Two cheers for conscience exceptions. Hastings Cent Rep.
2006 Nov-Dec;36(6):11-2. PubMed PMID: 17278865.
- In a recent discussion of conscience exceptions in medicine, Julian
Savulescu writes: "If people are not prepared to offer legally permitted,
efficient, and beneficial care to a patient because it conflicts with
their values, they should not be doctors."1 Such strong statements
have an appeal for anyone who laments that reproductive health
services may be available de jure but in some parts of the United States
are unavailable de facto. . .
Ralph Baergen, Christopher Owens
- Pharmacists' refusals to fill prescriptions for emergency
contraceptives for reasons of conscience have contributed to a national
debate regarding the permissibility of such actions. Some in the medical
community assert that pharmacists ought not to refuse to dispense
emergency contraceptives on this basis. Three lines of argument have
become prominent in defense of that position . . .
- In her Comment (April 15, p 1219),1 Katrina Bramstedt highlights
conscientious objection by US pharmacists to the prescription of
emergency contraception. Readers might be interested to learn the
position with regard to pharmacists working in Great Britain who might
have similar objections. . .
Ian Bennett, Abigail Calkins Aguirre, Jean Burg,
Madelon L. Finkel, Elizabeth Wolff, Katherine Bowman, Joan Fleischman
- Objectives: Early abortion is a common outpatient procedure, but few
family medicine residencies provide abortion training. We wished to
assess experiences and obstacles among residency programs that have
worked to establish early abortion services.
Methods: From 2001â€“2004, 14
faculty participated in a collaborative program to initiate abortion
training at seven family medicine residencies. Ten focus groups with all
trainees were followed by individual semi-structured interviews with a
smaller group (n=9) that explored the progress and obstacles they
experienced. Individual interviews were recorded and analyzed to identify
major themes and sub-themes related to initiating abortion training.
Results: Five of seven sites established abortion training. Five major
themes were identified: (1) establishing support, (2) administration, (3)
finance, (4) legal matters, and (5) security/demonstrators. Faculty from
sites where training was ultimately established rated the sub-themes of
billing/reimbursement, obtaining staff support, and state/hospital
regulations as most difficult. Gaining support from within the department
and institution was most difficult for the two sites that could not
establish training. None experienced difficulty with security/demonstrators.
Conclusions: Developing the clinical and administrative capacity to provide
early abortion services in family medicine residency programs is
feasible. Support from leadership within departments and from the wider
institution is important for implementation.
- The short essay by Jacob M. Appel, "May Doctors Refuse Infertility
Treatments to Gay Parents?" (July-August 2006) raises interesting
questions about the limits of conscience exemptions for health
professionals. The discussion explores these issues in relation to an
ongoing California case, Benitez v. NCWC, in which a lesbian seeking
infertility treatments is suing her physicians for refusing to assist her
because of their religious objections. . .
Julie D. Cantor
- Ritual genital cutting for women, a common practice in Africa and
elsewhere around the world, remains dangerous and controversial. In recent
years, a 14-year-old girl living in Sierra Leone exsanguinated and died
following a ritualistic genital cutting. Hoping to avoid that fate, women
with backgrounds that accept ritual genital cutting may, when they reach
majority age, ask plastic surgeons to perform genital alterations for
cultural reasons. Although plastic surgeons routinely perform cosmetic
procedures, unique ethical and legal concerns arise when an adult female
patient asks a surgeon to spare her the tribal elder's knife and alter
her genitalia according to tradition and custom. Misinformation and
confusion about this issue exist. This article explores the ethical and
legal issues relevant to this situation and explains how the thoughtful
surgeon should proceed.
Charu A. Chandrasekhar
- Introduction: In January 2005, a Wisconsin mother of six children
who experienced condom failure after intercourse ohtained a prescription for
emergency contraception and traveled to a Milwaukee Walgreens to fill the
prescription. Instead of honoring the physician's medical instructions,
however, pharmacist Michelle Long refused to fill the
prescription and "publicly berated" the customer, telling her, 'You're a
murderer. I will not help you kill this baby. I will not have the blood
on my hands.'' Although the customer tried to reason with the pharmacist,
the pharmacist's castigation only escalated. . .
Frank A. Chervenak, Laurence B. McCullough
- Savulescu's account of conscientious objection in medicine is a bold
statement that requires all obstetricians to perform abortions,
regardless of any moral convictions that they may have to the
contrary. Unfortunately, he violates the standards of argument based
ethics. . .
Peter A. Clark
- To circumvent objections that the death penalty was "cruel and unusual
punishment" and therefore a violation of the Eighth Amendment to the
Constitution, advocates proposed lethal injection and the involvement of
physicians to overcome the negative perceptions associated with the death
penalty, and to increase public acceptability of the practice. Initiated
in 1982, lethal injection is now the primary method of execution in 37 of
the 38 states with the death penalty. . .
Mary K. Collins
- Introduction: A busy mother of two runs by her neighborhood
pharmacy to refill her birth control pills, a routine chore she has
engaged in monthly for the past year. The pharmacist tells her, "I
personally don't believe in birth control and therefore I'm not going to
fill your prescription." Increasing numbers of pharmacists and
physicians are refusing to dispense or prescribe these forms of pregnancy
prevention, citing moral objections to hormonal contraceptives like the
Pill. The objections are based on the belief that hormonal methods of
contraception are abortifacients; that is, that the use of these methods
will result in the destruction of a fertilized egg. . .
Croxatto HB, Fernéndez SD.
Emergency contraception - a
human rights issue. Best Pract Res Clin Obstet Gynaecol. 2006
Jun;20(3):311-22. Epub 2006 Feb 9. PubMed PMID: 16480928.
Bernard M. Dickens
- Abstract: This paper addresses laws and practices urged by conservative
religious organizations that invoke conscientious objection in order to
deny patients access to lawful procedures. Many are reproductive health
services, such as contraception, sterilization and abortion, on which
women's health depends. Religious institutions that historically served a
mission to provide healthcare are now perverting this commitment in order
to deny care. Physicians who followed their calling honourably in a
spirit of self-sacrifice are being urged to sacrifice patients' interests to
promote their own, compromising their professional ethics by conflict of
interest. The shield tolerant societies allowed to protect religious
conscience is abused by religiously-influenced agencies that beat it into
a sword to compel patients, particularly women, to comply with religious
values they do not share. This is unethical unless accompanied by
objectors' duty of referral to non-objecting practitioners, and
governmental responsibility to ensure supply of and patients' access to
Dietz LH, Jacobs A, Leming TL , Kennel JR. Duty to Refer Patient to Specialist or Qualified Practitioner.
61 Am. Jur. 2d Physicians, Surgeons, and Other Healers 214 (2006).
- Introduction: As Americans increasingly integrate
religion into their daily lives, "conscience clause" statutes are
proliferating and influencing professional conduct across the United States. Conscience
clauses allow Americans to practice religion not only in their homes and
places of worship, but also in their professions. These statutes exempt
individuals and entities from legal requirements that conflict with their
religious beliefs, and they often become controversial when they pit one
citizen's religious freedom against another's health or safety. . .
- Abstract: Despite substantial controversy, the use of futility judgments in
medicine is quite common, and has been backed by the implementation of
hospital policies and professional guidelines on medical futility. The
controversy arises when health care professionals (HCPs) consider a
treatment futile which patients or families believe to be worthwhile:
should HCPs be free to refuse treatments in such a case, or be required
to provide them? Most physicians seem convinced that professional
autonomy protects them from being forced to provide treatments they judge
medically futile, given the lack of patient benefit as well as the waste
of medical resources involved. The argument from professional autonomy
has been presented in a number of articles, but it has not been subjected
to much critical scrutiny. In this paper I distinguish three versions of
the argument: 1) that each physician should be free to exercise his or
her own medical judgment; 2) that the medical profession as a whole may
provide futility standards to govern the practice of its members; and 3)
that the moral integrity of each physician serves as a limit to treatment
demands. I maintain that none of these versions succeeds in overcoming
the standard objection that futility determinations involve value
judgments best left to the patients, their designated surrogates, or
their families. Nor do resource considerations change this fact, since
they should not influence the properly patientcentered judgment about
John A. Gans
- The commentary by Wall and Brown was striking in its intentional
blurring of pharmacist refusals with unethical obstruction of patient
access to medications, its ignorance of contemporary pharmacy
practice, and its lack of citation of the positions of health care
professional organizations. . .
Dismembering the ethical physician.
Postgrad Med J 2006;82:233â€“238. doi:10.1136/pgmj.2005.037754
Stephen J. Genuis
- Physicians may experience ethical distress when they are caught in
difficult clinical situations that demand ethical decision making,
particularly when their preferred action may contravene the expectations
of patients and established authorities. When principled and competent
doctors succumb to patient wishes or establishment guidelines and
participate in actions they perceive to be ethically inappropriate, or
agree to refrain from interventions they believe to be in the best
interests of patients, individual professional integrity may be
diminished, and ethical reliability is potentially compromised. In a
climate of ever-proliferating ethical quandaries, it is essential for the
medical community, health institutions, and governing bodies to pursue a
judicious tension between the indispensable regulation of physicians
necessary to maintain professional standards and preserve public safety,
and the support for ''freedom of conscience'' that principled physicians
require to practise medicine in keeping with their personal ethical
Glasberg AL, Eriksson S, Dahlqvist V, Lindahl E, Strandberg
G, Söderberg A,
Sørlie V, Norberg A.
Development and initial validation of the Stress of
Conscience Questionnaire. Nurs Ethics. 2006 Nov;13(6):633-48. PubMed
Ann-Louise Glasberg, Sture Eriksson, Vera Dahlqvist, Elisabeth Lindahl,
Gunilla Strandberg, Anna Söderberg, Venke Sørlie, Astrid Norberg
- Stress in health care is affected by moral factors. When people are
prevented from doing 'good' they may feel that they have not done what
they ought to or that they have erred, thus giving rise to a troubled
conscience. Empirical studies show that health care personnel sometimes
refer to conscience when talking about being in ethically difficult
everyday care situations. This study aimed to construct and validate the
Stress of Conscience Questionnaire (SCQ), a nine-item instrument for
assessing stressful situations and the degree to which they trouble the
conscience. The items were based on situations previously documented as
causing negative stress for health care workers. Content and face
validity were established by expert panels and pilot studies that selected
relevant items and modified or excluded ambiguous ones. A convenience
sample of 444 health care personnel indicated that the SCQ had acceptable
validity and internal consistency (Cronbach's alpha exceeded 0.83 for the
overall scale). Explorative factor analysis identified and labelled two
factors: 'internal demands' and 'external demands and restrictions'. The
findings suggest that the SCQ is a concise and practical instrument for
use in various health care contexts.
- The emerging popularity of medical "conscience clauses" has been attracting attention most notably in the pharmaceutical field. Conscience clauses are laws that explicitly allow for health care workers to opt out of certain procedures, usually reproductive and end-of-life therapies, on moral, ethical, or religious grounds. Within medical circles, a doctor's right to refuse to offer specific treatments in a nonemergency setting, so long as alternative treatment options are provided, is well known and reinforced by state and federal laws and the American Medical Association's
Code of Medical Ethics. But for other health care workers,
including pharmacists, there is neither legislative support nor a rich
professional tradition that allows for conscientious objection. . .
- How should the government respond if people refuse standard medical
treatment? What should the government do if people refuse medical
treatment for their children, and what autonomy should teenagers be given
in making such choices? Is religion a proper basis for refusing such
medical treatment? Furthermore, should medical practitioners have a
privilege not to render services that they object to in conscience? This
article analyzes such questions and proposes that the most sensible
answers depend on context. Legislatures should sometimes create no
exemptions, should sometimes create exemptions based on nonreligious
criteria, and should sometimes use criteria framed in terms of religion.
As a matter of constitutional law, statutes may often use religion as a
criterion for a privilege, but even then, legislatures may choose broader
- Critics of conscience clauses have held that such statutes should be
narrowly restricted to purely sectarian institutions. Any type of
connection to the public world would require the institution, and the
people operating within it, to conform to secular principles. In short,
such critics argue that if an individual or institution is "[i]n the
public world, they should play by public rules." Such a test would add
to another requirement prior to validation of a conscience clause that
no burden be imposed on any other individual. Any type of burden that
would be imposed on another person by a pharmacist's morally or
religiously motivated refusal would be grounds to nullify the exemption.
Introduction: Pharmacists are now at the forefront of the controversy
surrounding abortion and contraception. In recent years, some
pharmacists, motivated by religious or moral scruples, have refused to
dispense birth control and emergency contraception (EC) to their female
customers.'' As a result, women's efforts to obtain contraception have
been frustrated. The earliest report of a pharmacist who refused to
dispense EC was in 1991. Since then, pharmacists across the country have
acted on their beliefs and denied women access to contraception. . .
Elizabeth Murray,Paquita de Zulueta
- We question Savulescu's statement
that a specialist valuing her own life more than her duty to her patients
during a bird flu epidemic would be demonstrating values
"incompatible with being a doctor." By 6 February 2006 the World
Health Organization had received reports of 165 confirmed cases of
avian influenza in humans, of whom 88 had died (mortality 53%). The
Department of Health's influenza pandemic contingency plan estimates an
attack rate of 25% and a case fatality rate of 0.37%.3 Health care
staff are likely to be particularly at risk, with estimated sickness
absence rates double the rate of the general population. . .
Conscientious objection in medicine.
BMJ. 2006 February 4; 332(7536): 294â€“297.
- Shakespeare wrote that "Conscience is but a word cowards use, devised
at first to keep the strong in awe" (Richard III V.iv.1.7). Conscience,
indeed, can be an excuse for vice or invoked to avoid doing one's duty.
When the duty is a true duty, conscientious objection is wrong and
immoral. When there is a grave duty, it should be illegal. A doctors'
conscience has little place in the delivery of modern medical care. What
should be provided to patients is defined by the law and consideration
of the just distribution of finite medical resources, which requires a
reasonable conception of the patient's good and the patient's informed
desires (box). If people are not prepared to offer legally permitted,
efficient, and beneficial care to a patient because it conflicts with
their values, they should not be doctors. Doctors should not offer
partial medical services or partially discharge their obligations to care
for their patients. . .
Vaughn P. Smith
- Since visiting Auschwitz, I have grappled with the question of how I would
have behaved as a doctor in Nazi Germany or Stalinist Russia. I hope I
would have had the moral courage to refuse to participate in the
various perversions of medicine that these regimes demanded - for example,
respectively, eugenic "research" and psychiatric "treatment" of
dissidents. . .
- In 2002, a University of Wisconsin student brought a prescription
for Loestrin to pharmacist Neil Noesen, who was working in a local
community phannacy in Menomonie, Wisconsin. Noesen refused to fill
the prescription, citing his "conscientious objection to
participation in refilling a contraceptive order." He failed to ask
the student whether she had any medical conditions that might make
pregnancy dangerous. He also refused to inform her of any other local
pharmacies that were capable of filling the prescription. 3 When the
student, on her own, located another pharmacy, Noesen refused to
transfer the prescription, claiming that doing so would "induce
another to do a morally wrong or sinful act pursuant to the doctrines
of the Roman Cathoiic Church." As a result, the student was unable to
Â·take her medication as prescribed and risked pregnancy. . .
Robert K. Vischer
- Introduction: "The Religion then of every man must be left to the
conviction and conscience of every man; and it is the right of every man
to exercise it as these may dictate."
With these words, James Madison helped derail proposed legislation that
would have provided taxpayer funding "for Teachers of the Christian
Religion" in Virginia. Over the ensuing 220 years, Madison's sentiment
has become a fixture of the American constellation of non-negotiable
ideals. Religious devotion is a matter for individual conscience, not
external coercion. As a citizeny, we comprise hundreds of wildly
divergent faiths (including a rising number claiming no faith), and thus
our common life requires uncommon tolerance, whether as a function of
principle or simple survival.
L. Lewis Wall, Douglas Brown
- Over the past several months, numerous instances have been reported
in the United States media of pharmacists refusing to fill prescriptions
written for emergency postcoital contraceptives. These pharmacists
have asserted a "professional right of conscience" not to participate
in what they interpret as an immoral act. . .
L. Lewis Wall, Douglas Brown
- We thank Dr. Gans for his interest in our commentary. We are pleased
that the organizations he represents are willing to go on record as
opposing pharmacists who deliberately obstruct patient access to
legitimate prescription medications. Likewise, we are pleased that he
is willing to denounce pharmacists who use their position at the
counter as a pulpit to advance their personal beliefs. Activities of this
kind by pharmacists are becoming increasingly common and should be
opposed by all health care professionals.
Mark R. Wicclair
- Abstract: This paper examines the obligations of
pharmacy licensees and pharmacists in the context of conscience-based
objections to filling lawful
prescriptions for certain types of medications - e.g., standard and emergency
contraceptives. Claims of conscience are analyzed as means to preserve or
maintain an individual's moral integrity. It is argued that pharmacy
licensees have an obligation to dispense prescription medications that
satisfy the health needs of the populations they serve, and this
obligation can override claims of conscience. Although efforts should be
made to respect the moral integrity of pharmacists and accommodate their
claims of conscience, it is argued that the health needs of patients and
the professional obligations of pharmacists limit the extent to which
pharmacists may refuse to assist patients who have lawful prescriptions
for medically indicated drugs.
Susan C. Winckler, John A. Gans
- Two articles in this issue of the Journal relate to emergency
contraception. Borrego et al report results of research to assess
pharmacists' knowledge, attitudes, and beliefs toward prescribing oral
emergency contraception, and Monastersky and Landau provide their
perspectives on pharmacists' efforts to expand consumer access to
emergency contraception through collaborative practice agreements.
Inherent in such discussions is the conscience clause issue, through
which individual pharmacists can choose to opt out of participating in
activities that conflict with their personal beliefs. As reflected
in Tables 1 and 2, the American Pharmacists Association (APhA)
supports both this conscience clause as well as expanded access to
emergency contraception through collaborative practice agreements, and
these positions have sparked questions about the apparent disconnect
between the two concepts. . .