Armand H. Matheny Antommaria
- Abstract: The analysis of a dispute can focus on either
interests, rights, or power. Commentators often frame the conflict over
conscience in clinical practice as a dispute between a patient's right to legally
available medical treatment and a clinician's right to refuse to provide
interventions the clinician finds morally objectionable. Multiple sources
of unresolvable moral disagreement make resolution in these terms
unlikely. One should instead focus on the parties' interests and the
different ways in which the health care delivery system can accommodate
them. In the specific case of pharmacists refusing to dispense emergency
contraception, alternative systems such as advanced prescription,
pharmacist provision, and over-the-counter sales may better reconcile the
client's interest in preventing unintended pregnancy and the pharmacist's
interest in not contravening his or her conscience. Within such an
analysis, the ethicist's role becomes identifying and clarifying the
parties' morally relevant interests.
Askin J. Physicians need freedom of conscience. Medical Post 44.16
(Jun 13, 2008): 11-12.
- Abstract: Medically trained English philosopher Dr. John Locke (1632-1704) held
that freedom of conscience is the basis of individual rights, thereby
limiting intrusion by the state into the lives of its citizens. Although
Canada has recognized this as the first fundamental freedom in the Charter
of Rights and Freedoms, anyone who has argued a human rights case knows
just how costly and trying such a suit can be.
Moral courage through a collective voice. Am J
Bioeth. 2008 Apr;8(4):67-9; author reply W3-4. PubMed PMID: 18576265.
- Hoas (2008), I could not help but question whether some of the ethical
issues highlighted by the authors are unique to rural healthcare, such as
the lack of moral courage among healthcare professionals to take action
when unethical situations arise. In discussing some of these rural,
ethical issues amongmycolleagues, medical residents, and students, who
have observed and practiced rural healthcare, I not only confirmed what
the authors thoroughly researched, but a thoughtful and reflective
discussion about their own experiences and some of the unique ethical
challenges they face ensued. The point is: discourse is a critical
starting point for addressing and resolving these ethical problems and
issues in rural healthcare. Discussions among diverse groups of rural and
urban healthcare professionals and patients can foster a unified
understanding of the politics, emotions, and values that continue to
impair moral courage and ethical action. In this commentary I discuss
various pedagogical approaches for fostering moral courage such as
collective discourse, intended to serve as a companion to the three
conditions, outlined by Cook and Hoas (2008), surrounding a healthcare
provider's willingness to take action, including: "the extent to which
one: 1) recognizes an issue as ethically problematic, 2) believes that
the repercussions of one's actions can be handled, and 3) believes
that positive changes will occur as a result of one's efforts" (52). . .
Beal MW, Cappiello J.
Professional right of conscience. J
Midwifery Womens Health. 2008 Sep-Oct;53(5):406-12; quiz 487-8. PubMed PMID:
Margaret W. Beal, CNM, PhD, and Joyce Cappiello,
- In recent years there have been numerous media reports of professionals
attempting to expand the right of conscience and deny health care
services requested by consumers. While the media has focused the most
attention on pharmacists' right to refuse access to contraception, this
trend is an expansion of the right originally established to protect
professionals from being required to perform abortions or to provide
direct assistance with abortions. State legislatures have addressed this
issue, in some cases by overtly protecting consumers' rights and in other
cases by broadening professional right of conscience. In this article,
the literature on provider right of conscience is reviewed, and approaches
advised by professional organizations are discussed.
Dan W. Brock
- Abstract: Some medical services have long generated deep
moral controversy within the medical profession as well as in broader
society and have led to conscientious refusals by some physicians to provide those services to
their patients. More recently, pharmacists in a number of states have
refused on grounds of conscience to fill legal prescriptions for their
customers. This paper assesses these controversies. First, I offer a
brief account of the basis and limits of the claim to be free to act on
one's conscience. Second, I sketch an account of the basis of the medical
and pharmacy professions' responsibilities and the process by which they
are specified and change over time. Third, I then set out and defend what I
call the ''conventional compromise'' as a reasonable accommodation to
conflicts between these professions' responsibilities and the moral
integrity of their individual members. Finally, I take up and reject the
complicity objection to the conventional compromise. Put together, this
provides my answer to the question posed in the title of my paper:
"Conscientious refusal by physicians and pharmacists: who is obligated
to do what, and why?".
Robert A. Buerki
- Any consideration of the conscience clause in American pharmacy begs a
consideration of the concept of "conscience," and how this moral value
has affected the practice of America's pharmacists. Conscience may be
seen as an inherited intuitive sense that has evolved over thousands
of years of human existence, an innate sense of righ~ and wrong, or
simply a set of values derive<, l. from individual experiences. There are
three distinct arenas in which conscience may be exercised:
individual conscience, religious conscience, and professional conscience.
Lucy M. Candib
- As a family physician educator, I am proud to see that the editor of
Family Medicine recognized theimportance of publishing the articles by
Dehlendorf and Brahmi on abortion training in family medicine
residency training programs. . .
Julie D. Cantor
- A new rule from the Department of Health and Human Services (DHHS) has emerged as the latest battleground in
the health care conscience wars. Promulgated during the waning months
of the Bush administration, the rule became effective in January.
Heralded as a "provider conscience regulation" by its supporters and
derided as a "midnight regulation" by its detractors, the rule could alter
the andscape of federal conscience law. . .
Carlin K, Burcher B.
Conscientious Objection: An Ethical Perspective during a Health
ICNE YALE #66
Kathleen Carlin, Betty Burcher
- Abstract: During health emergencies, whether pandemics or natural or
man-made disasters, there is an increased demand for nurses and other health
care workers to care for the sick or injured and to protect the well-being
of the whole community. In fact, in many jurisdictions there may be
emergency legislation compelling health workers to work during a crisis.
In anticipation of potential crises like a pandemic influenza, nurses have
deliberated on their responsibilities during a major health emergency and
have articulated that during a health emergency they would feel pulled
between their obligations to their patients, their families and their own
well. While during the SARS outbreak in 2003 nurses were lauded for "going
above and beyond the call of duty", an alternative perspective is
that "one's obligations to oneself are no less moral in character than one's
obligation to others."
Historically, conscientious objection has been
used to decline service in the military for moral reasons; it has also been
adopted by nurses and other health professionals declining
to work in patient-care areas or
take part in procedures that are not compatible with their values.
This paper will examine the utility
of conscientious objection as an ethical perspective during a health
emergency: individual nurses deciding whether obligations to themselves
and/or to their families morally outweigh professional obligations.
Considering this choice as a genuine ethical dilemma may help nurses in
their decision making and help others understand nurses' decisions.
Frank A. Chervenak, Laurence B. McCullough
- Referral of pregnant patients for termination of pregnancy by physicians
morally opposed to the procedure is ethically controversial, with
polarized positions taken by physician organizations. Based on the
ethical principles of beneficence and respect for autonomy, we establish
the distinction between direct and indirect referral. Direct referral is
beneficence based and requires the referring physician to ensure that the
referral occurs. Indirect referral is autonomy based, with a
beneficence-based component that requires that the physician provide
information to the patient about health care organizations that will
provide competent medical care. We show that only indirect referral is
ethically required in healthy women for termination of an unwanted
pregnancy or a pregnancy complicated by fetal anomalies because the
indications for this procedure are solely autonomy based. Direct referral
for termination of pregnancy is not ethically required but is
permissible. Conscience-based objections to direct referral for termination
of pregnancy have merit; conscience-based objections to indirect referral
Frank A. Chervenak, Laurence B. McCullough
- In their article "Of More than One Mind: Obstetrician-Gynecologists'
Approaches to Morally Controversial Decisions in Sexual and Reproductive
Healthcare," Farr Curlin, Shira Dinner, and Stacy Tessler Lindau report
the results of a qualitative study of self-reported attitudes of
obstetrician-gynecologists toward decision making in the ethically
controversial clinical area of reproductive healthcare. Qualitative
research is useful for the generation of significant hypothesis. Curlin,
Dinner, and Lindau generate such a hypothesis: "within the one
profession of obstetrics and gynecology, there are different and
dissonant ideas about how a caring physician should approach medical
decision making in areas of moral ambiguity." Curlin, Dinner, and Lindau
are entirely correct to state: "These differences have implications for
ob/ gyns and their patients. ". . .
Gary W. Clark, Ross Colt, Douglas Maurer, Kelly Latimer, Richard W. Sams
II, Gordon Zubrod
- Imagine the following introduction to a future article in Family
Medicine: "Providing comprehensive care across the life cycle is a core
value in family medicine. One element of comprehensive care is office-
and home-based procedures. Euthanasia of the infirm elderly, mentally
retarded, and disabled infants is a procedural skill well suited to the
strengths of family physicians. Limited attention has been given to this
procedure. Our study was designed to determine the barriers to providing
euthanasia services to patients." . . .
Morals, medicine and geography. CMAJ. 2008 Nov
4;179(10):996-7. PubMed PMID: 18981435; PubMed Central PMCID: PMC2572650.
- The US government recently proposed a rule that will force hundreds
of thousands of health agencies to prove that they are not compelling
doctors to perform or make referrals for - or even provide clinical
information about - controversial procedures like abortion and
sterilization. Health policy changes north of the 49th parallel
suggest Canada is heading in a different direction. Doctors in both
countries have been prompted by new guidelines to reconsider the
effects of restricting physicians' freedom of conscience. Some believe
it will demoralize a segment of the profession and drive many to seek
new careers. Others claim that patients' rights to access legal services
make restrictions necessary. . .
Farr A. Curlin
- Physicians sometimes refuse to provide legally permitted medical services
on the grounds that they cannot do so in good conscience. Such
conscientious refusals are at least as old as the Hippocratic movement.
Yet new events, such as the refusal by health care professionals to
prescribe or dispense post-coital ("emergency") contraception, have
kindled new debates about what physicians are obligated to do when
patients request legal medical interventions to which their physicians have
moral objections. In a recent national survey, we found that a large
majority of physicians believe they are obligated in such circumstances
to present all possible options to the patient, including information
about obtaining the requested intervention, and to refer the patient to a
clinician who does not object to the requested intervention. Yet a
substantial minority of physicians - particularly those who are more
religious and/or who themselves object to common controversial
practices-disagree with these majority opinions . . .
Alice S. Day
- It was 5 p.m. on a Monday in a rural town when a 17-year-old high
school senior arrived
at the practice as the last walk-in patient of the day. She explained
to the nurse practitioner (NP) that during sexual intercourse with her
boyfriend on Friday evening, the condom had broken and she was afraid
that she might become pregnant. She had been away for the weekend,
arrived home late the night before and had attended a full schedule of
classes on Monday. She had wanted to seek help earlier but felt she
needed to be at all her classes for fear of her grades slipping and her
eligibility for a college scholarship diminishing. She was hoping to
be the first member of her family to go to college. . .
Conscientious commitment. The Lancet, Volume 371, Issue 9620,
Pages 1240 - 1241, 12 April 2008
- In some regions of the world, hospital policy, negotiated with the
health ministry and police, requires that a doctor who finds evidence of
an unskilled abortion or abortion attempt should immediately inform
police authorities and preserve the evidence. Elsewhere, religious
leaders forbid male doctors from examining any part of a female
patient's body other than that being directly complained about. Can a
doctor invoke a conscientious commitment to medically appropriate and
timely diagnosis or care and refuse to comply with such directives?
Christine Dehlendorf, Kevin Grumbach, Carole Joffe,
Dalia Brahmi, Marji Gold, David Engel
- While we are well aware there are differences of opinion regarding
the morality of abortion, as described by Clark et al, our paper was
not designed to address this issue. Rather, given that abortion is
legal, is within the scope of family medicine, and one of the procedures
most frequently sought by our patients, we believe that family physicians
should have the opportunity to receive training in this procedure if
they desire. . .
- Objectives: Assess attitudes
toward prenatal diagnosis (PND) and termination of pregnancy (TOP) for Down
syndrome (DS), hemophilia, lethal autosomal recessive disorder (LRD) and a
hypothetical late-onset neurodegenerative disorder (NDD) among healthcare
workers in one Sri Lankan district.
Methods: Self-administered questionnaire
(tested for content validity) completed by medical (n = 218) and nursing (n
= 368) students, nurses (n = 178) and doctors (n = 127).
Acceptability of PND was 94%, 91%, 86% and 71% respectively for LRD, DS,
hemophilia and NDD. Favorable attitudes toward TOP for DS (84%), and LRD
(82%) were higher compared with hemophilia (65%) and NDD (53%). There was
willingness to consider TOP for self/spouse for DS (79%), LRD (78%),
hemophilia (60%) and NDD (54%). The proportions willing to participate in a
pregnancy termination (DS 54%, LRD 51%, hemophilia 38%, NDD 38%) were lower.
Religious affiliation influenced attitudes regarding TOP with Christians
being more opposed than Buddhists.
Conclusions: There is acceptance of and
willingness to participate in TOP for fetal anomalies among Sri Lankan
healthcare workers. These findings have relevance for developing prenatal
diagnostic services in Sri Lanka. Religious affiliation among Asian doctors,
nurses (and patients) in developed countries is likely to determine
permissiveness toward PND and TOP.
Conscientious commitment. Lancet. 2008 Apr
12;371(9620):1240-1. PubMed PMID: 18415961.
Bernard M. Dickens
- In some regions of the world, hospital policy, negotiated with the
health ministry and police, requires that a doctor who finds evidence of
an unskilled abortion or abortion attempt should immediately inform
police authorities and preserve the evidence. Elsewhere, religious
leaders forbid male doctors from examining any part of a female patient's
body other than that being directly complained about. Can a doctor invoke
a conscientious commitment to medically appropriate and timely diagnosis
or care and refuse to comply with such directives? . . .
- Abstract: In Brazil, social science research ethics
is a held still under construction and subject to intense dispute. The
aim of this paper is to discuss how accepted principles of biomedical
research ethics can be incorporated into the ethical review of social
sciences, particularly open interviews, ethnographic research, and
participant observation. The paper uses a case study - the ethnographic
documentary Severinas Story - as the basis for analysis of the
methodological and ethical issues raised in social science research. To
promote ethical social science research, based on principles such as
human rights and the protection of vulnerable populations, institutional
review boards must be sensitive to the epistemological and
methodological particularities of all fields of human subjects research.
- The introduction of conscience clauses after the 1973 US Supreme Court
decision in Roe v. Wade allowed physicians and nurses to opt out of
medical procedures, particularly abortions, to which they were morally
opposed. In recent years pharmacists have requested the same
consideration with regard to dispensing some medicines. This paper
examines the pharmacists' role and their professional and moral
obligations to patients in the light of recent refusals by pharmacists to
dispense oral contraceptives. A review of John Rawls's concepts of the
"original position" and the "veil of ignorance", along with
consideration of the concept of compartmentalisation, are used to assess
pharmacists' requests and the moral and legal rights of patients to have
their prescriptive needs met.
Førde R, Aasland OG.
Moral distress among Norwegian doctors. J
Med Ethics. 2008 Jul;34(7):521-5. PubMed PMID: 18591286.
R. Førde R, O.G. Aasland
- Abstract: Background: Medicine is full of value conflicts. Limited
resources and legal regulations may place doctors in difficult ethical dilemmas and
cause moral distress. Research on moral distress has so far been mainly
studied in nurses.
Objective: To describe whether Norwegian doctors
experience stress related to ethical dilemmas and lack of resources, and
to explore whether the doctors feel that they have good strategies for
the resolution of ethical dilemmas.
Design: Postal survey of a
representative sample of 1497 Norwegian doctors in 2004, presenting
statements about different ethical dilemmas, values and goals at their
Results: The response rate was 67%. 57% admitted that it is
difficult to criticise a colleague for professional misconduct and 51%
for ethical misconduct. 51% described sometimes having to act against own
conscience as distressing. 66% of the doctors experienced distress
related to long waiting lists for treatment and to impaired patient care
due to time constraints. 55% reported that time spent on administration
and documentation is distressing. Female doctors experienced more
stress than their male colleagues. 44% reported that their workplace
lacked strategies for dealing with ethical dilemmas.
of resources creates moral dilemmas for physicians. Moral distress varies
with specialty and gender. Lack of strategies to solve ethical dilemmas
and low tolerance for conflict and critique from colleagues may
obstruct important and necessary ethical dialogues and lead to suboptimal
solutions of difficult ethical problems.
Discrimination on the basis of ethical orientation.
Can Fam Physician. 2008 Dec;54(12):1679-80. PubMed PMID: 19074702; PubMed
Central PMCID: PMC2602643.
Stephen J. Genuis
- Dr. Diane Kelsall's insightful editorial "Whose right?" highlights
some of the challenges associated with the policy proposed by the College
of Physicians and Surgeons of Ontario (CPSO) relating to restriction of
"freedom of conscience" for clinicians. It is troubling enough that the
Ontario Human Rights Commission (OHRC) perceives it has the clinical
perspicacity as well as the jurisdictional authority to arbitrate in
complex matters relating to physician-patient relationships; it is
even more perplexing that the CPSO would entertain such an infringement
on their professional membership. . . .
Ann-Louise Glasberg, Sture Eriksson, Astrid Norberg
- Aim: The main purpose of this study was to examine factors related to
'stress of conscience' i.e. stress related to a troubled conscience in
Methods: A series of questionnaires was completed by 423 healthcare
employees in northern Sweden as part of this cross-sectional study. The
series of questionnaires comprised the 'Stress of Conscience
Questionnaire', 'Perception of Conscience Questionnaire', 'Revised Moral
Sensitivity Questionnaire', Social Interactions Scale, Resilience Scale
and a Personal/Work Demographic form.
Results: Nonautomatic stepwise regression analysis with forward
inclusion resulted in a model that explained approximately 39.6% of the
total variation in stress of conscience. Individual items associated with
stress of conscience were; perceiving that conscience warns us against
hurting others while at the same time not being able to follow one's
conscience at work and having to deaden one's conscience to keep working
in healthcare. In addition moral sensitivity items belonging to the
factor 'sense of moral burden' were; one's ability to sense patient's
needs means that one is doing more than one has strength for, having
difficulty to deal with feelings aroused when a patient is suffering and
one's ability to sense patient's needs means feeling inadequate all added
significantly to the model. In addition, deficient social support from
superiors, low levels of resilience and working in internal medicine
wards were all associated with stress of conscience.
Conclusion: Healthcare employees seem to experience stress of
conscience in their everyday practise. Particular contributing factors
are not being able to follow one's conscience at work, and the 'negative'
dimension of moral sensitivity â€“ moral burden â€“ which is an inability to
deal with moral problems. Thus, in order for conscience and moral
sensitivity to become an asset instead of a burden, healthcare employees
need to be able to express their moral concerns.
John J. Hardt
- This article critically evaluates the conception of conscience underlying
the debate about the proper place and role of conscience in the clinical
encounter. It suggests that recovering a conception of conscience rooted
in the Catholic moral tradition could offer resources for moving the
debate past an unproductive assertion of conflicting rights, namely,
physicians' rights to conscience versus patients' rights to socially and
legally sanctioned medical interventions. It proposes that conscience is
a necessary component of the moral life in general and a necessary
resource for maintaining a coherent sense of moral agency. It demonstrates
that an earlier and intellectually richer conception of conscience, in
contrast with common contemporary formulations, makes the judgments of
conscience accountable to reason, open to critique, and protected from
becoming a bastion for bigotry, idiosyncrasy, and personal bias.
- On 10 October 2008 following a highly charged emotional debate and an
historic conscience vote in State Parliament, abortion was decriminalised
in Victoria. For many observers this reform was long overdue and simply
brought the law into line with common practice in Victoria. It also
meant that women having abortions and the doctors who performed them no
longer risked criminal prosecution, which if successful carried a
penalty of up to 10 years jail, a consequence that supporters regarded as
unconscionable. . .
Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin
- Aims. The aim was to study the relationship between conscience and
burnout among care-providers in older care, exploring the relationship
between stress of conscience and burnout, and between perceptions of
conscience and burnout.
Background. Everyday work in healthcare presents
situations that influence careproviders' conscience. How care-providers
perceive conscience has been shown to be related to stress of conscience
(stress related to troubled conscience), and in county council care, an
association between stress of conscience and burnout has been found.
Method. A questionnaire study was conducted in municipal housing for older
people. A total of 166 care-providers were approached, of which 146 (50
registered nurses and 96 nurses' aides/enrolled nurses) completed a
questionnaire folder containing the stress of conscience questionnaire,
the perceptions of conscience questionnaire and the maslach burnout
inventory. Multivariate canonical correlation analysis was used to
Result. The relationship between stress of
conscience and burnout indicates that experiences of shortcomings and of
being exposed to contradictory demands are strongly related to burnout
(primarily to emotional exhaustion). The relationship between perceptions
of conscience and burnout indicates that a deadened conscience is
strongly related to burnout.
Conclusion. Conscience seems to be of importance in relation to burnout,
and suppressing conscience may result in a profound loss of wholeness,
integrity and harmony in the self.
Relevance to clinical practice. The
results from our study could be used to raise awareness of the importance
of conscience in care.
- Abstract: This article explores the issue of
conscientious objection invoked by health professionals in the reproductive
and sexual health care context and its impact on women's ability to access
health services. The right
to exercise conscientious objection has been recognized by many
international and European scholars as being derived from the right to
freedom of thought, conscience and religion. It is not, however, an absolute
right. When the exercise of conscientious objection conflicts with other
human rights and fundamental freedoms, a balance must be struck between
the right to conscientious objection and other affected rights such as
the right to respect for private life, the right to equality and
non-discrimination, and the right to receive and impart information.
Particularly in the reproductive health care context, states that allow
health professionals to exercise conscientious objection must accommodate
this in such a way that its exercise does not compromise women's access
to health services. Th is article analyses the European Court of Human
Rights' decision on admissibility in Pichon and Sajous v. France (2001) and
argues that a balancing approach should be applied in cases of
conscientious objection in the sexual and reproductive health care
John D. Lantos, Farr A. Curlin
- Consider the following three cases: A paediatrician is called to the
delivery room as a woman is about to give birth to a premature baby at
24 weeks. The mother and father request that the baby not be
resuscitated. The baby weighs 760 grams and has an Apgar score of 6 at 1
min. The paediatrician ignores the parents' requests for comfort care
and intubates the baby.
A full-term baby with Trisomy 18 develops cyanosis.
An echocardiogram reveals a large ventricular septal defect. The parents
request surgery. The cardiac surgeon refuses to operate based upon the
baby's poor prognosis for a 'reasonable quality of life.'
A 15-year old girl is seen for a sports physical. She
asks for a prescription for birth control pills and asks the paediatrician
not to tell her parents that she is sexually active or using oral
contraceptives. The doctor refuses to prescribe the pills without parental
permission. . .
Allyson J. Lipp
- Abstract: Aim: To review the literature on attitudes of health care professionals to
termination of pregnancy and draw out underlying themes.
Background: The controversy surrounding therapeutic abortion is unremitting with
public opinion often polemic and unyielding. Nurses and midwives are at
the centre of this turmoil, and as more termination of pregnancies are
being performed using pharmacological agents, they are becoming ever
more involved in direct care and treatment. Attitudes towards
termination of pregnancy have been found to vary depending on the
nationality of those asked, the professionals involved, experience in
abortion care, as well as personal attributes of those asked such as
their obstetric history and religious beliefs. The reasons for women
undergoing abortion were also found to influence attitudes to a greater
or lesser extent.
Conclusion: This paper explores research studies undertaken into attitudes of
health care professionals towards termination of pregnancy, to
appreciate the complexity of the debate. It is possible that the
increased involvement of nurses in termination of pregnancy, that
current methods demand, may lead to change in attitudes. Consideration
is given to a number of remedies to create an optimum environment for
women undergoing termination of pregnancy.
Relevance to clinical practice: This paper establishes via a literature review that attitudes in
those working in this area of care depend upon a variety of influences.
Suggestions are made for measures to be put into place to foster
appropriate attitudes in those working in termination of pregnancy
- This essay sets down three directives for conscientiously objecting
clinicians - physicians, particularly obstetrician/gynecologists, trained
in NaProTechnology by the Pope Paul VI Institute and Creighton University
School of Medicine and any medical professionals who share their natural
law vision of reproductive health care- to protect their right to
well-formed conscientious objection in reproductive medicine. Directive
one: understand the nature of a wellformed conscience and its rightful
exercise. Directive two: fulfill all reasonable American College of
Obstetricians and Gynecologists' requirements for conscientious refusal.
Directive three: execute a political strategy to protect health-care
LVADs and the limits of autonomy.
(Letter) Hastings Cent Rep.
2008 May-Jun;38(3):4-5; author reply 5. PubMed PMID: 18584849.
- I read with concern the recent case study ("Doctor, Will You Turn
Off My LVAD?" Jan-Feb 2008) regarding deactivation of LVADs. Jere my
Simon's commentary argues that physicians may decline to deactivate an
LVAD even at the request of a capable patient. He finds that the
patient's right to decline any and all medical treatment does not apply
here since the LVAD, once implanted, is no longer a treat ment, but more
like a patient's organ. . .
- Objective: The aim of this study was to focus on barriers, controversy
and perceived risk associated with use of emergency contraception (EC)
after unprotected sexual intercourse.
Design and method: Data were
extracted from the literature of the MEDLINE database service. Original
articles, surveys, clinical trials and investigations are considered for
Results: After the introduction of over-the-counter and
advance prescription provisions for easy access to EC, the ruralâ€“ urban
disparity in availability of EC poses a barrier to use of EC for rural
dwellers. The socio-economically weaker section of the population is
unable to purchase EC because of low or no income, although there is
mounting pressure by the State for prevention of unintended pregnancy by
use of EC. Some healthcare providers have objected to provide EC to the
patient on the grounds of their conscience and morality. Some providers
and users have also expressed concerns about the possibility of increase
in irresponsible sexual behaviour because of easy access to EC. There may
be some truth in their apprehension because nearly 3.2 million unintended
pregnancies occur annually despite various contraceptive options available
in USA and the extensive use of EC is directly proportional to the volume of
unprotected sexual intercourse, which is too directly proportional to the
quantum of risk for contacting sexually transmitted infections (STIs) â„
Conclusions: Emergency contraception is a one-off postcoital
procedure and not to be opted after every sexual intercourse. Controversy
about EC may be resolved if it is used within this limit. Extensive use
of EC may increase risk for contacting STIs â„ AIDS.
Simon J, Fischbach R.
LVADs and the limits of autonomy.
(Author reply) Hastings Cent Rep. 2008 May-Jun;38(3):4-5; author reply 5.
PubMed PMID: 18584849
Jeremy Simon, Ruth Fischbach
- We thank Tia Powell for responding to our case commentary, but we
are puzzled by the strength of her reaction to Jeremy Simon's argument.
We do not consider its suggestions to be outside the bounds of law or
ethics. To make the argument sharper, consider an internally powered,
fully self-contained, implantable artificial heart with no external
connections, which, while not currently available, is certainly not
fantasy. Powell would argue that a patient has the right to have this
device removed should he desire. We believe that this claim is
debatable, as we do not see a clear ethical difference between a fully
implanted mechanical heart and a transplanted biological heart, which no
physician would remove, even at a patient's request. . .
Abstract: Some argue that law is the discipline
which has mixed most prominently with bioethics, and that bioethicists can
be seduced by the law and by legal procedures. While there is a great
consensus that law has influenced bioethics in significant and important
ways, certainly much more than it influenced other "law and..." disciplines,
scholars dispute as to the exact role which the law plays in bioethics, the
goals it purports to achieve and the implications of its relationship with
the discipline of bioethics. This Article aims to explore the relationship
between law and bioethics and calls for a careful evaluation of the law's
contributions to bioethics. Specifically, it will be argued that while the
law contributed extensively to the development of bioethics it introduced a
language and a way of thinking that are not necessarily appropriate to
handle and resolve bioethical issues, and which, in significant portion of
cases, was irrelevant and had little impact on decision-making and
behavioral patterns of patients. Moreover, law's interference with and shape
of bioethical issues resulted in serious threats to some of the major
characteristic of such issues and brought about to other societal concerns
which the law did not consider seriously. The article will conclude that it
is now time to re-evaluate the direction in which bioethics should take in
the next years, specifically whether it should continue to integrate with
law or other disciplines, or alternatively become a more autonomous and
Jennifer E. Spreng
Abstract: Stories abound of both women with
prescriptions turned away at the pharmacy door and members of the most
trusted health care
profession losing jobs and running afoul of ethics rules. Scholars have
spilt much intellectual ink divining whether a pharmacist must dispense
Plan B, the primary emergency contraceptive. Now, many are calling for a
common law "duty to dispense" that could serve as a foundation for a
wrongful pregnancy action against a dissenting pharmacist. Such a duty
simply does not arise from established tort principles or
pharmacist-specific precedents. Only in rare circumstances will a
pharmacist and customer have the type and quality of relationship giving
rise to a duty to dispense. Nevertheless, law changes over time and makes
allowances for unique circumstances. Pharmacists are taking on more
responsibility for drug therapy. They have an awkward role in the
distribution of Plan B. Moreover, while the law may protect pharmacists' consciences, it may not be so receptive to pharmacists-as-activists.
Dissenting pharmacists can take practical steps to protect themselves
today, but tomorrow is another day.
- Introduction: The United States Food and Drug Administrationâ€™s decisions in the past
decade to approve both RU-486
and Plan B have created crises of conscience for some religious
pharmacists. RU-486 induces abortion in the first trimester of
pregnancy without surgical intervention and Plan B is a two-pill
"emergency contraceptive" regimen that may have abortifacient
properties. Some religious pharmacists prefer not to dispense the drugs
because their religious scruples forbid them from participating in
abortions. Some also object to dispensing daily oral
contraceptives6 on the same basis.
- This article introduces the life of Shomatsu Yokoyama ( 1913-1992),
a physiologist and military doctor, to the reader. During the
Sino-Japanese war, Yokoyama disobeyed orders given by his superior
officer to conduct inhumane medical experiments on humans.
Not only in Unit 731, but also in other units, many
military doctors were involved in medical crimes against residents of the
areas invaded by the Japanese Army. Inhumane living-body experiments and
vivisections were widely conducted at that time.
There were, however, a small number of researchers
who did not follow the orders to perform human body experiments.
Highlighting the life of such a rare researcher for the purpose of
ascertaining the reason for his noncompliance with the order will provide us
with insights on medical ethics.
When Yokoyama was a student, his teacher, Professor
Rinya Kawamura, informed him that he had been requested by the army to
conduct special experiments. The remuneration for conducting such
experiments was over 10 times more than the research fund allocated to the
professor. Kawamura declined the request on the grounds that accepting it
was against humanity. Kawamura warned Yokoyama that he might face the same
situation in the future and asked Yokoyama to mark his words.
Yokoyama was called to Ko-1855 Unit in 1944 and
ordered to carry out living-body experiments by his superior officer. He
disregarded the order, remembering Kawamura's words. As a result, he was
dispatched to the dangerous frontlines.
This article explores why Yokoyama was able to
disobey the order to conduct inhumane experiments while shedding light on
his personal background and his relationship with Rinya Kawamura. This
article chronicles the life of one medical researcher who followed the
dictates of his conscience during and after the war.
Daniel P. Sulmasy
- Abstract: The literature on conscience in medicine has
paid little attention to what is meant by the word 'conscience.' This
article distinguishes between retrospective and prospective conscience,
distinguishes synderesis from conscience, and argues against intuitionist
views of conscience. Conscience is defined as having two interrelated
parts: (1) a commitment to morality itself; to acting and choosing
morally according to the best of one's ability, and (2) the activity of
judging that an act one has done or about which one is deliberating would
violate that commitment. Tolerance is defined as mutual respect for
conscience. A set of boundary conditions for justifiable respect for
conscientious objection in medicine is proposed.
Alexander C. Tsai
- Savulescu's analysis and comment on conscientious objection in
medicine would benefit from a more carefully drawn distinction between
conscientious objectors in the public vs. private sector. Savulescu
(2007) writes that physician conscientious objection could affect
"potentially 40 million American patients" and refusal to refer could
affect "potentially 100 million American patients", but he makes no
distinction between whether they are seeking care in the public vs.
private sector. . .
Tully P. Morally Objectionable Options Informed Consent and Physician
Integrity. National Catholic Bioethics Quarterly, Autumn, 2008 491-504
Patrick A. Tully
- Recent and forthcoming medical technologies and practices (e.g., in vitro
fertilization, somatic cell nuclear transfer, oocyte-assisted reprogramming,
the creation of chimeras and "savior siblings") are likely to multiply
the occasions for a type of dilemma that physicians have long faced: What
are doctors to do when a treatment that they believe to be seriously
morally wrong is available and indicated for one of their patients? . . .
Helen von Kohlen
In this work the institutionalisation of Hospital Ethics Committees in the
USA and in Germany will be analysed by focussing on nurses' participation
and the representation of caring issues. Therefore, questions about the
design of Hospital! Ethics Committees and how their practices really look
like, will be raised. The central question is, how the tradiÂtional care
ethos of the helping professions in medicine and nursing can find its place
in discussions of these committees while hospitals have increasingly been
organised along economic criteria.
The comparative research combines a literature study, expert interviews and
historiÂcal analysis of Hospital Ethics Committees in the USA (first part)
with an investigation into theoretical approaches that understand care as a
practice (second part). The empirical study of Ethics Committees in Germany
took place over two
years in three Ethics ComÂmittees in a Lutheran
hospital, a Catholic hospital and a Communal one that had
been privatised. The
field study is based on participant observations and interviews.
For the overall research, Adele Clarke's work of
Situational Analysis: (2005)
proved to be fundamental since it offered to combine historical, conceptual
and ethnographic apÂproaches. The gathered data were structured and
interpreted in the framework of qualitative
The analysis of the US- American development shows under which influences a
new type of consultation, namely multidisciplinary ethics consultation as a
shared-deciÂsion-making process could unfold. Personal fates like
the story of Karen Quinlan and the so-called "Baby-Doe-Cases" contributed to
the establishment of Hospital Ethics Committees. An acceleration of the
growth of these committees were accreditation processes of hospitals that would demand such an
instrument to deal with ethical conflicts. USÂ American governmental
intervention could also support its development, mainly to prevent
Nurses' participation in US- American Hospital Ethics Committees has been a
matÂter of concern since the 1980is. Studies could show that nurses were
members of these committees, but they would not bring in their unique
ethical issues. In order to focus more on nurses'
specific conflicts, between 1980 and 1990
Nursing Ethics Committees were
established. Discussions in Hospital Ethics Committees were framed by a
principle based model. Respect for autonomy became the leading principle.
Hereby, conflicts with regard to a practices of care
were rather marginalized. Nevertheless,
a debate about care ethics took place
in the nursing scientific community when Carol Gilligan had published her
research In a Different Voice (1982). In the 1990's mainly
political (feminist) ethicists worked on theoretical approaches to
understand care as a practice. The refined underÂstanding of care by Joan
Trento, Margaret Urban Walker and Elisabeth Conradi were especially helpful
to describe the unseen work of care in the data given by the participant
observations and Interviews
in the field work show
that care practices in the
tradition of Hippocratic Medicine are no longer self-evident for the
helping professions. Physicians and nurses do rather struggle for a care
ethos especially with regard to end-of-life questions and regulations of
tube-feeding. The "cases" for ethics consultation brought into the
committees by physicians and nurses did not rarely emerge as social problems
and as a lack of professional competence. The problems appeared to be
solvable by transÂlating them into a language of principles and making the
process manageable. These principle-based discussions in the practical
arena of the hospital resemble discourse practices embedded within the
larger bioethical debates on the political arena. Technical proceÂdures
given my management and administration do fit into the use of abstract
principles and contribute to a language that limits the
possibilities to think - what is at stake for
patients - in terms of caring
relations rather than thinking in terms of rules, regulations and control.
Jerome R. Wernow, Donald G. Grant
- Background: For over 30 years, pharmacists have exercised the right to
dispense medications in accordance with moral convictions based upon a
Judeo- Christian ethic. What many of these practitioners see as an
apparent shift away from this time-honored ethic has resulted in a
challenge to this right.
Objective: To review and analyze pharmacy
practice standards, legal proceedings, and ethical principles behind
conflicts of conscientious objection in dispensing drugs used for
Data sources: We first searched the terms
conscience and clause and Plan B and contraception and abortion using
Google, Yahoo, and Microsoft Networks (2006â€“September 26, 2008). Second,
we used Medscape to search professional pharmacy and other medical
journals, restricting our terms to conscience, Plan B, contraceptives,
and abortifacients. Finally, we employed Loislaw, an online legal
archiving service, and did a global search on the phrase conscience clause
to determine the status of the legal discussion.
Data synthesis: To
date, conflicts in conscientious objection have arisen when a pharmacist
believes that dispensing an oral contraceptive violates his or her moral
understanding for the promotion of human life. Up to this time, cases in
pharmacy have involved only practitioners from orthodox Christian faith
communities, primarily devout Roman Catholics. A pharmacist's right to
refuse the dispensing of abortifacients for birth control according to
moral conscience over against a woman's right to reproductive birth
control has created a conflict that has yet to be reconciled by licensing
agents, professional standards, or courts of law.
analysis of prominent conflicts suggests that the underlying worldviews
between factions make compromise improbable. Risks and liabilities are
dependent upon compliance with evolving state laws, specific disclosure of a
pharmacist's moral objections, and professionalism in the handling of
volatile situations. Objecting pharmacists and their employers should
have clear policies and procedures in place to minimize workplace
conflicts and maximize patient care.
Mark R. Wicclair
Abstract: In response to physicians who refuse to
provide medical services that are contrary to their ethical and/or
religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and
professionally permitted medical services should choose another
profession. This article critically examines the underlying assumption
that conscientious objection is incompatible with a physician's professional
obligations (the "incompatibility thesis"). Several accounts of the
professional obligations of physicians are explored: general ethical
theories (consequentialism, contractarianism, and rights-based theories),
internal morality (essentialist and non-essentialist conceptions),
reciprocal justice, social contract, and promising. It is argued that
none of these accounts of a physician's professional obligations
unequivocally supports the incompatibility thesis.
Robin Fretwell Wilson
- Introduction: Refusals by individual pharmacies and pharmacists to fill
prescriptions for emergency contraceptives ("EC") have dominated news
headlines, from the Washington Post to the Miami Herald. In the act that
sparked a firestorm of controversy, an Eckerd pharmacist refused to fill
a rape victim's prescription for Plan B. A few months later, 11 Alabama
nurses resigned positions at state clinics rather than provide EC against
their moral convictions. These refusals do not seem to be driven by
moral concerns about promiscuity, since pharmacists have refused to
dispense Plan B to married couples as well. Instead, the refusals
reflect moral and religious concerns about facilitating an act that would
cut-off a potential human life. . .