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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers



Alarcon C. The Hijacking of Moral Conscience from Pharmacy Practice: A Canadian Perspective.  Annals of Pharmacotherapy, Apr 2009; 43: 748 - 753.

  • . . . The introduction of discriminatory legislation into North American pharmacy practice that began in the mid-1990s is a sign of the times. . .Ensuing policies promote patient choice above all else and take no account of the democratically protected rights of freedom of conscience, religion, and expression of all individuals. . .

American Academy of Pediatrics Committee on Bioethics. Policy statement--Physician refusal to provide information or treatment on the basis of claims of conscience. Pediatrics. 2009 Dec;124(6):1689-93. PubMed PMID: 19948636.

  • Abstract: Health care professionals may have moral objections to particular medical interventions. They may refuse to provide or cooperate in the provision of these interventions. Such objections are referred to a conscientious objections. Although it may be difficult to characterize or validate claims of conscience, respecting the individual physician's moral integrity is important. Conflicts arise when claims of conscience impede a patient's access to medical information or care. A physician's conscientious objection to certain interventions or treatments may be constrained in some situations. Physicians have a duty to disclose to prospective patients treatments they refuse to perform. As part of informed consent, physicians also have a duty to inform their patients of all relevant and legally available treatment options, including option to which they object. They have a moral obligation to refer patients to other health care professionals who are willing to provide those services when failing to do so would cause harm to the patient, and they have a duty to treat patients in emergencies when referral would significantly increase the probability of mortality or serious morbidity. Conversely, the health care system should make reasonable accommodations for physicians with conscientious objections

Baker R. Conscience and the unconscionable. Bioethics. 2009 Jun;23(5):ii-iv. Review. PubMed PMID: 19476456.

  • A year ago I sat between a Catholic priest and a bioethicist on a panel debating President Bush's initiative to extend 'antidiscrimination' protections to health professionals who refuse to perform a 'legal medical service or procedure' for 'reasons of conscience.' These 'civil rights' protections were designed to protect health professionals against their professional societies and their employers who, the Bush administration claimed, 'would force physicians to either violate their conscience by referring patients for abortions . . . or risk losing their board certification,' or their job. As Assistant Secretary of Health Garcia, MD, explained, 'health providers shouldn't have to check their conscience at the hospital door. The proposed rule will help ensure that doesn't happen.' . . .

Cantor JD. Conscientious Objection Gone Awry - Restoring Selfless Professionalism in Medicine.  N Engl J Med 360;15 april 9, 2009

  • 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 landscape of federal conscience law. . .

Bhattacharya D. (2009) Conflicts of Conscience in Health Care.  Journal of Legal Medicine, 30:2, 289-298, DOI: 10.1080/01947640902937827

  • Introduction: The confluence of modern technology, skill, and medical necessity allows health care providers to occupy a unique position that inevitably invites moral scrutiny. To some, ensuring access to contraceptives, abortions, or assisted reproductive therapy is inherently inexcusable (their legality notwithstanding). For others, modern medicine ought to be a patient-driven enterprise with physicians as mere facilitators who provide services in response to patient'wants. Lost in this debate at the extremes is a recognition that moral dilemmas emerge from instances of human suffering, a complex phenomenon from which nobody-including physicians-are immune. In issues of conscience and moral quandaries, parsing rights, duties, and ethical obligations is challenging for both providers and patients. Indeed, physicians are people too.

Bradley CT. Emergency contraception and physicians' rights of conscience: a review of current legal standards in Wisconsin. WMJ. 2009 May;108(3):156-60. Review. PubMed PMID: 19552354.

  • Abstract:  Recent legislation in Wisconsin mandating provision of emergency contraception to victims of sexual assault may create a conflict of conscience for some health care professionals. Although disputes exist over the exact mechanism of action of emergency contraception, those professionals who espouse a particularly strict stance may be reluctant to dispense the medication for fear that it could prevent a fertilized embryo from implanting in the uterus. While no objection of conscience clause was written into the new law, Wisconsin law has a long tradition of recognizing rights of conscience in matters of religious conflict. This legal tradition both at statutory and common law levels is summarized with application to the recent emergency contraception mandate. A case is made for a potential legal defense should a health care professional abstain from dispensing emergency contraception.

Card R. Federal provider conscience regulation: unconscionable. J Med Ethics. 2009 Aug;35(8): 471-2. PubMed PMID: 19644003.

  • Abstract:  This paper argues that the provider conscience regulation recently put into place in the USA is misguided. The rule is too broad in the scope of protection it affords, and its conception of what constitutes assistance in the performance of an objectionable procedure reveals that it is unworkable in practice. Furthermore, the regulation wrongly treats refusal of other reproductive services as on a par with conscientious objection to participation in abortion. Finally, the rule allows providers to refuse even to discuss  "objectionable " options with patients and serves to protect discriminatory refusals of medical care. For all of these reasons, this regulation is unwise.

Chervenak FA, McCullough LB. An ethically justified practical approach to offering, recommending, performing, and referring for induced abortion and feticide. Am J Obstet Gynecol. 2009 Dec;201(6):560.e1-6. Epub 2009 Sep 17. PubMed PMID: 19762005.

  • Abstract: We provide comprehensive, practical guidance for physicians on when to offer, recommend, perform, and refer patients for induced abortion and feticide. We precisely define terminology and articulate an ethical framework based on respecting the autonomy of the pregnant woman, the fetus as a patient, and the individual conscience of the physician. We elucidate autonomy-based and beneficence-based obligations and distinguish professional conscience from individual conscience. The obstetrician's role should be based primarily on professional conscience, which is shaped by autonomy-based and beneficence- based obligations of the obstetrician to the pregnant and fetal patients, with important but limited constraints originating in individual conscience.

Cook RJ, Olaya MA, Dickens BM. Healthcare responsibilities and conscientious objection. Int J Gynaecol Obstet. 2009 Mar;104(3):249-52. Epub 2008 Nov 29. PubMed PMID: 19041970.

  • Abstract: The Constitutional Court of Colombia has issued a decision of international significance clarifying legal duties of providers, hospitals, and healthcare systems when conscientious objection is made to conducting lawful abortion. The decision establishes objecting providers' duties to refer patients to non-objecting providers, and that hospitals, clinics, and other institutions have no rights of conscientious objection. Their professional and legal duties are to ensure that patients receive timely services. Hospitals and other administrators cannot object, because they do not participate in the procedures they are obliged to arrange. Objecting providers, and hospitals, must maintain knowledge of non-objecting providers to whom their patients must be referred. Accordingly, medical schools must adequately train, and licensing authorities approve, non-objecting providers. Where they are unavailable, midwives and perhaps nurse practitioners may be trained, equipped, and approved for appropriate service delivery. The Court's decision has widespread implications for how healthcare systems must accommodate conscientious objection and patients' legal rights.

Davis S, Lansing P.  When Two Fundamental Rights Collide at the Pharmacy: The Struggle to Balance the Consumer’s Right to Access Contraception and the Pharmacist’s Right of Conscience. 12 Depaul J. Health Care L. 67, 89-91 (2009)

  • Introduction:  The dangerous intersection between a pharmacist's right of moral belief and a woman's right of contraceptive use continues to be an important topic for debate across the nation. In fact, the area of contraceptive rights has been a controversial issue since the United States Supreme Court's decision in Griswold v. Connecticut in 1965, which recognized a constitutional right of privacy in family planning decisions implicit within the meaning of the Bill of Rights. Now, over forty years since this landmark decision, courts continue to grapple with the notion of women's rights and how contraceptive use should be protected. 

    New developments in pharmaceutical research and technology have resulted in the formation of new legal and ethical issues. The most recent dilemma faced by both federal and state courts features women who desire a recently FDA approved contraceptive drug called Plan B and pharmacists who are morally opposed to the mode of action of the drug. This newfound ability to prevent birth using a drug taken after sexual activity presents a scenario the Griswold Court would have never anticipated. Nonetheless, the precedent beginning with Griswold has created a necessary collision between these two fundamental rights.

    Pharmacists are placed in a unique position in this controversy. Pharmacists are licensed by the state yet some believe that they cannot comply with state requirements due to their individual religious beliefs. As nearly all Americans are familiar, the right to religious belief has been protected since the drafting of the Bill of ...

Dickens BM. Legal protection and limits of conscientious objection: when conscientious objection is unethical. Med Law. 2009 Mar;28(2):337-47. PubMed PMID: 19705646.

  • Abstract: The right to conscientious objection is founded on human rights to act according to individuals' religious and other conscience. Domestic and international human rights laws recognize such entitlements. Healthcare providers cannot be discriminated against, for instance in employment, on the basis of their beliefs. They are required, however, to be equally respectful of rights to conscience of patients and potential patients. They cannot invoke their human rights to violate the human rights of others. There are legal limits to conscientious objection. Laws in some jurisdictions unethically abuse religious conscience by granting excessive rights to refuse care.. In general, healthcare providers owe duties of care to patients that may conflict with their refusal of care on grounds of conscience. The reconciliation of patients' rights to care and providers' rights of conscientious objection is in the duty of objectors in good faith to refer their patients to reasonably accessible providers who are known not to object. Conscientious objection is unethical when healthcare practitioners treat patients only as means to their own spiritual ends. Practitioners who would place their own spiritual or other interests above their patients' healthcare interests have a conflict of interest, which is unethical if not appropriately declared.

Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009 Winter;20(4):330-42. PubMed PMID: 20120853.

  • Introduction: First defined by Jamtjton in 1984 as a phenomenon that occurs when nurses cannot carry out what they believe to be ethically appropriate actions because of institutional constraints, moral distress has recently gained attention as an important problem experienced by multiple healthcare disciplines.  Although it is not a new topic, recent attention to moral distress (specifically, an article in the New York Times by surgeon Pauline W. Chen, "When doctors and nurses can't do the right thing, " and a fourfold increase in articles on the topic in MEDLINE in the past two years) has highlighted its presence and effect on healthcare providers and on the delivery of healthcare. While the majority of published research has been in nursing journals, current work has expanded to other disciplines, including medicine, psychology, pharmacy, and respiratory therapy. It is increasingly clear that moral distress is not solely a nursing issue, but one that potentially influences all healthcare professionals. . .

Freyd JJ. Rules of conscience. Betray ethics, betray trust. (Letter) BMJ. 2009 Jun 1;338:b2191. doi: 10.1136/bmj.b2191. PubMed PMID: 19487323.

  • The harm caused by the interrogation methods described by Pope and Gutheil goes far beyond the considerable damage, sometimes fatal, of methods commonly understood to be torture. . .

Gerrard JW. Is it ethical for a general practitioner to claim a conscientious objection when asked to refer for abortion? J Med Ethics. 2009 Oct;35(10):599-602. PubMed PMID: 19793938.

  • Abstract:  Abortion is one of the most divisive topics in healthcare. Proponents and opponents hold strong views. Some health workers who oppose abortion assert a right of conscientious objection to it, a position itself that others find unethical. Even if allowance for objection should be made, it is not clear how far it should extend. Can conscientious objection be given as a reason not to refer when a woman requests her doctor to do so? This paper explores the idea of the general practitioner (GP) who declines to make a direct referral for abortion, asking the woman to see another GP instead. The purpose is to defend the claim that an appeal to conscientious objection in this way can be reasonable and ethical.

Grealis C.  Religion in the Pharmacy: A Balanced Approach to Pharmacists' Right to Refuse to Provide Plan B. 97 Geo. L.J. 1715, 1722-26 (2009)



Harries J, Stinson K, Orner P. Health care providers' attitudes towards termination of pregnancy: A qualitative study in South Africa. BMC Public Health 2009,9:296 doi:10.1186/1471-2458-9-296

  • Background: Despite changes to the abortion legislation in South Africa in 1996, barriers to women accessing abortion services still exist including provider opposition to abortions and a shortage of trained and willing abortion care providers. The dearth of abortion providers undermines the availability of safe, legal abortion, and has serious implications for women's access to abortion services and health service planning.

In South Africa, little is known about the personal and professional attitudes of individuals who are currently working in abortion service provision. Exploring the factors which determine health care providers' involvement or disengagement in abortion services may facilitate improvement in the planning and provision of future services.

Methods: Qualitative research methods were used to collect data. Thirty four in-depth interviews and one focus group discussion were conducted during 2006 and 2007 with health care providers who were involved in a range of abortion provision in the Western Cape Province, South Africa. Data were analysed using a thematic analysis approach.

Results: Complex patterns of service delivery were prevalent throughout many of the health care facilities, and fragmented levels of service provision operated in order to accommodate health care providers' willingness to be involved in different aspects of abortion provision. Related to this was the need expressed by many providers for dedicated, stand-alone abortion clinics thereby creating a more supportive environment for both clients and providers. Almost all providers were concerned about the numerous difficulties women faced in seeking an abortion and their general quality of care. An overriding concern was poor pre and post abortion counselling including contraceptive counselling and provision.

Conclusion: This is the first known qualitative study undertaken in South Africa exploring providers' attitudes towards abortion and adds to the body of information addressing the barriers to safe abortion services. In order to sustain a pool of abortion providers, programmes which both attract prospective abortion providers, and retain existing providers, needs to be developed and financial compensation for abortion care providers needs to be considered.

Project note:  A survey was undertaken in 1996.  See  Are State Doctors in the Western Cape willing to implement the Choice of Termination of Pregnancy Act of 1996?

Harty-Golder B. Pregnancy tests cause crisis of conscience. MLO Med Lab Obs. 2009 Dec;41(12):52. PubMed PMID: 20085095.

  • Q.  A technologist in my lab refuses to perform pregnancy tests from a local crisis pregnancy clinic. She claims it violates her conscience, because she feels most of the women getting these tests will go on to have abortions. She feels the same way about genetic testing. Can we force her to do these tests? They are in the usual course of her work, and her refusal is causing problems, mostly because of strong political opinions on the subject. . .

Iqbal S, Skogstad P. Rules of conscience. BMJ's poor portrayal of issues. (Letter) BMJ. 2009 Jun 1;338:b2190. doi: 10.1136/bmj.b2190. PubMed PMID: 19487322.

  • The headline on the cover of the BMJ's 16 May issue, "Interrogating detainees: why psychologists participate and doctors don't," is, at best, an example of poor communication. It violates Grice's maxims of good communication: avoid obscurity of expression, make your contribution one that is true, and be sufficiently informative. . .

Jensen A, Lidell E. The influence of conscience in nursing. Nurs Ethics. 2009 Jan;16(1):31-42. PubMed PMID: 19103689.

  • The influence of conscience on nurses in terms of guilt has frequently been described but its impact on care has received less attention. The aim of this study was to describe nurses' conceptions of the influence of conscience on the provision of inpatient care. The study employed a phenomenographic approach and analysis method. Fifteen nurses from three hospitals in western Sweden were interviewed. The results showed that these nurses considered conscience to be an important factor in the exercise of their profession, as revealed by the descriptive categories: conscience as a driving force; conscience as a restricting factor; and conscience as a source of sensitivity. They perceived that conscience played a role in nursing actions involving patients and next of kin, and was an asset that guided them in their efforts to provide high quality care.

Kagan PN, Smith MC, Cowling WR, Chinn PL.  A nursing manifesto: an emancipatory call for knowledge development, conscience, and praxis.  Nursing Philosophy (2009), 11, pp. 67–84

  • The purpose of this paper is to present the theoretical and philosophical assumptions of the Nursing Manifesto, written by three activist scholars whose objective was to promote emancipatory nursing research, practice, and education within the dialogue and praxis of social justice. Inspired by discussions with a number of nurse philosophers at the 2008 Knowledge Conference in Boston, two of the original Manifesto authors and two colleagues discussed the need to explicate emancipatory knowing as it emerged from the Manifesto. Our analysis yielded an epistemological framework based on liberation principles to advance praxis in the discipline of nursing. This paper adds to what is already known on this topic, as there is not an explicit contribution to the literature of this specific Manifesto, its significance, and utility for the discipline.While each of us have written on emancipatory knowing and social justice in a variety of works, it is in this article that we identify, as a unit of knowledge production and as a direction towards praxis, a set of critical values that arose from the emancipatory conscience-ness and intention seen in the framework of the Nursing Manifesto.

Kane R. Conscientious objection to termination of pregnancy: the competing rights of patients and nurses. Journal of Nursing Management, 2009, 17, 907–912 DOI: 10.1111/j.1365-2834.2008.00888.x

  • This paper explores the issue of conscientious objection and looks specifically at ways in which it may be managed to minimize its effect on patients. It discusses how the issue of conscientious objection is addressed in practice and examines some of the issues surrounding access to abortion services and the potential impact of staff attitudes on accessibility. The way in which conscientious objection is managed within the law and within professional codes of conduct is then explored.

Laabs CA. Nurses and Conundrums of Conscience. Forum on Public Policy: A Journal of the Oxford Round Table; 2009, Vol. 5 Issue 1, Special section p1.

  • Abstract: There is controversy today concerning conscience, conscientious objection, and health care professionals. Nurses reportedly have said that they are expected to "set aside" or "deaden" their conscience to work in health care. Given the morally serious work that nurses do, this expectation is puzzling and concerning. It suggests a misunderstanding of the meaning of conscience, a conundrum which could be contributing to the persistent problem of nurses' moral distress and to the chronic shortage of nurses. This conundrum may be confounding efforts by society to formulate coherent policy on conscience and conscientious objection by health care professionals. In this essay I offer reflections on various understandings of conscience as they relate to nurses. I suggest that when conscience is conceptualized in terms of relativism and subjectivism, setting aside one's conscience may seem possible and even understandable in a morally pluralistic society. However, conscience may not be entirely subjective or relative but, rather, deep-seated and grounded in objective moral norms, and, as a result, it is difficult to completely ignore one's conscience and troubling to act contrary to it. Because persons of good will may disagree in their conscientious judgments, tolerance, or mutual respect for conscience, is needed. Thus, reasoned discussions are necessary to formulate policy on conscientious objection that is coherent, morally defensible and avoids misunderstandings. It is my hope that this essay contributes to the discussion and to clearing up the conundrums.

Lawrence RE, Curlin FA. Physicians' beliefs about conscience in medicine: a national survey. Acad Med. 2009 Sep;84(9):1276-82. PubMed PMID: 19707071; PubMed Central PMCID: PMC2859045.

  • Abstract: Purpose: To explore physicians' beliefs about whether physicians sometimes have a professional obligation to provide medical services even if doing so goes against their conscience, and to examine associations between physicians' opinions and their religious and ethical commitments.

Method: A survey was mailed in 2007 to a stratified random sample of 1,000 U.S. primary care physicians, selected from the American Medical Association Physician Masterfile. Participants were classified into three groups according to agreement or disagreement with two statements: "A physician should never do what he or she believes is morally wrong, no matter what experts say," and "Sometimes physicians have a professional ethical obligation to provide medical services even if they personally believe it would be morally wrong to do so."

Results: The response rate was 51% (446/879 delivered questionnaires). Forty-two percent and 22% believed they are never and sometimes, respectively, obligated to do what they personally believe is wrong, and 36% agreed with both statements. Physicians who are more religious are more likely to believe that physicians are never obligated to do what they believe is wrong (58% and 31% of those with high and low intrinsic religiosity, respectively; multivariate odds ratio, 2.9; 95% CI, 1.2–7.2). Those with moral objections to any of three controversial practices were more likely to hold that physicians should never do what they believe is wrong.

Conclusion:  A substantial minority of physicians do not believe there is ever a professional obligation to do something they personally believe is wrong.

Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.  Clinical Psychology Review 29 (2009) 695–706

  • Abstract:  Throughout history,warriors have been confronted with moral and ethical challenges andmodern unconventional and guerilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearingwitness to acts that transgress deeply held moral beliefs and expectationsmay be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.

Leong R.  Debates: Do FPs agree on what professionalism is? No. Canadian Family Physician Vol 55: October 2009

  • Pellegrino defines professionalism as "those qualities and modes of conduct proper to professions." In each patient encounter, the physician, as a professional, "professes" both technical competence and a commitment to use that competence in the patient's best interest. A good physician is therefore characterized by virtues that enable him or her to achieve what he or she professes: benevolence, confi dentiality, compassion, and courage are just a few examples. Specific to family medicine, Dr Cal Gutkin, Chief Executive Officer of the College of Family Physicians of Canada, has identified  "key principles and actions" of professionalism, including knowledge, commitment to ongoing education, evidence-based practice, liability, self-regulation, and the provision of "ethical" and "altruistic" care. Given that the qualities described above are noble and worthy of emulation, one might wonder why FPs do not agree on what professionalism is. . .

May T, Aulisio MP. Personal morality and professional obligations: rights of conscience and informed consent. Perspect Biol Med. 2009 Winter;52(1):30-8. PubMed PMID: 19168942.

  • Abstract:  This article examines the issue of expanding rights of conscience for health-care professionals to include rights grounded in claims of complicity.Our concerns relate to the nature of professional expertise, on the one hand, and an individual's right to live by his or her values, on the other.The fact that a patient is dependent on a physician's counseling about treatment options requires limiting conscience-based refusal to provide information, since allowing refusal would deprive patients of even knowing the options that exist for them. Sanctioning such claims of conscience not only would supplant one person's moral judgment with another's, it would also allow professional standing to be used as a justification for imposing one person's moral views on another.

McHale JV. Conscientious objection and the nurse: a right or a privilege? Br J Nurs. 2009 Nov 12-25;18(20):1262-3. PubMed PMID: 20081664.

  • Abstract: This article examines to what extent nurses can at present opt out of clinical procedures on the basis of conscience in English law. It considers the current rights to opt out on the basis of conscience contained in section 4 of the Abortion Act 1967 and section 38 of the Human Fertilisation and Embryology Act 1990. It examines how through codes of practice and guidance, there is recognition of the ability to opt out beyond theses statutes. It suggests that rather than let practice evolve to enable persons to opt out, the fundamental issues as to whether it should be a right or a privilege needs careful consideration across healthcare professions as a whole and a broader public debate.

Mishtal JZ. Matters of "conscience": the politics of reproductive healthcare in Poland. Med Anthropol Q. 2009 Jun;23(2):161-83. Erratum in: Med Anthropol Q. 2009 Sept;23(3):356. PubMed PMID: 19562954.

  • The fall of state socialism in Poland in 1989 constituted a critical moment that redefined policies regulating reproductive health and access to care. As the Polish state adopted the discourse and agenda of the Catholic Church in its health policies, reproduction and sexuality became sites of moral governance through the implementation of the Conscience Clause law, which permits healthcare providers to deny medical services citing conscience-based objections. Based on ethnographic fieldwork, this article explores the effects of the implementation of the conscience clause and argues that the adoption of this law for individual use paved the way for restrictions on reproductive healthcare on a systemic scale. The special status afforded to the church is highly significant for access to health services deemed by the church to be matters of morality. The Polish case raises concerns about the place of women's rights in postsocialism and the nature of Polish democratization.

Morton NT, Kirkwood KW. Conscience and conscientious objection of health care professionals refocusing the issue. HEC Forum. 2009 Dec;21(4):351-64. PubMed PMID: 19856113.

  • Introduction: Recently a resurgence of interest in issues of conscience, as they relate to health care practice, has led to fervent writing on the topic. This paper will show the importance of respecting claims to conscience in light of its value for directing ethical decision making within the health care context. Although conscientious judgments may on occasion be erroneous or lead to conflict, it is best to respect conscientious warning and educate Health Care Professionals (HCPs) to examine and defend their beliefs. This paper will address the issue of defining conscience, and consider how that definition illuminates the contradictory nature of asking HCPs to act according to conscience on some occasions, but to ignore their conscience on others. These issues are addressed in light of conscientious objection and its potential relationship to moral distress.

Morris KL. Torture and attachment: conscience and the analyst's world-seeing eye. Psychoanal Rev. 2009 Oct;96(5):841-55. PubMed PMID: 19842923.

  • . . . It would seem as mad an approach to a discussion on the relationship between torture and attachment and the role of psychologists in the "Global War On Terror" (GWOT)-through the filters of medieval Persian poetry-as it would be through the rationality of behavioral science or ncuro-psychoanalysis. But to my mind, to sanction torture, to measure torture, to monitor torture, or to perform torture are all forms of the same madness, no matter how it is measured or by whom.

Ohto H, Yonemura Y, Takeda J, Inada E, Hanada R, Hayakawa S, Miyano T, Kai K, Iwashi W, Muto K, Asai F; Japanese Society of Transfusion Medicine and Cell Therapy (JSTMCT). Guidelines for managing conscientious objection to blood transfusion. Transfus Med Rev. 2009 Jul;23(3):221-8. PubMed PMID: 19539876.

  • Parents sometimes deny their children blood transfusion because of their religious beliefs. The Japanese Joint Committee on the Refusal of Blood Transfusion on Religious Grounds asserts that the health and life of every child younger than 15 years should be guarded by the collective efforts of health, welfare, and advocacy institutions when a parent or guardian seeks to withhold transfusion therapy. Patients 18 years or older should receive treatment without transfusion after signing andsubmitting a "Certificate of Refusal Blood Transfusion and Exemption from Liability." For a patient younger than 18 years, but 15 years or older, essential transfusion can be performed if the patient or at least one guardian consents. Without patient's or guardian's consent, guidelines for patients 18 years or older shall apply. Health care providers should offer the best possible care that is consistent with a patient's age and competency.

Oreb N. Worth the wait? A critique of the Abortion Act 2008 (Vic). J Law Med. 2009 Oct;17(2):261-9. PubMed PMID: 19998595.

  • This article offers a critique of the likely impact of the Abortion Act 2008 (Vic) in light of the fact that the Act was intended to reflect rather than alter current clinical practice surrounding abortion. The author traces the development of abortion law in Victoria and compares the two models for regulating abortion: the "common law model" and the "legislative model". The author argues in favour of legislative intervention. The author also discusses current uncertainties that exist due to the unclear effect of the Charter of Human Rights and Responsibilities Act 2006 (Vic) on abortion legislation, focusing on the intersection between women's rights to an abortion and doctors' rights to freedom of conscience.

Parr KA. Beyond politics: A social and cultural history of federal healthcare conscience protections. Am J Law Med. 2009;35(4):620-46. PubMed PMID: 20196285.

  •  Introduction: The day before the inauguration of his Democratic successor, President George W. Bush oversaw the promulgation of an administrative rule that extended "sweeping" new conscience protections to healthcare providers, one which would allow them to refuse to participate in or refuse to refer for medical services to which they morally or religiously object. Enacted in a funding regulation through the Department of Health and Human Services ("HHS"), the rule - commonly called the Provider Conscience Regulation ("Regulation") - purported to clarify and implement existing federal law; by its own terms; however, the Regulation pushed the boundaries of those laws, granting protections to a broader class of individuals and across a wider range of services. In so doing, the Regulation sought to resolve an ongoing tension between patient access and provider autonomy, yet it served to reignite a long-standing debate over the proper role of morals in medicine. . .

Pellegrino ED. Physician integrity: why it is inviolable. Hastings Cent Rep. 2009;Suppl:18-20. PubMed PMID: 19891271.

  • To deem itself civilized, a society must protect the personal integrity of its citizens. Without such protection, the integrity of the society itself unravels as more and more effort goes into protecting individuals against the chicanery of their fellow citizens. Perhaps this is why Plato called integrity "the goodness of the ordinary citizen." If integrity is the characteristic value for the ordinary citizen, then it's even more important for those whose social roles are defined primarily in terms of personal trust- doctors, lawyers, ministers, and teachers. Ordinary citizens cannot be healed- or provided with advocacy, spiritual counsel, or learning- without trust in these helping professions. (Unfortunately, history recounts how some physicians in every age have failed in the trustworthiness integral to medicine.) When such professions lack integrity, those who need their services will seek to protect themselves by assuring greater individual or public control over their relationships with these professions. . .

Recent Case: Constitutional law -- free exercise clause -- Ninth Circuit rejects strict scrutiny for pharmacy dispensing requirement. -- Stormans, Inc. v. Selecky, 571 F.3d 960 (9th Cir. 2009). Harv Law Rev. 2009 Dec;123(2):596-603. PubMed PMID: 20196268.

  • Excerpt: In the wake of Roe v. Wade, a public policy debate arose concerning the right of public health professionals and institutions to refuse to perform abortions based on religious and moral objections. Over the past two decades, that debate has expanded to encompass similarly grounded objections to other interventions. One quite controversial addition to that debate concerns so-called "emergency contraception," an intervention that involves high doses of contraceptives taken within seventy-two hours after intercourse to prevent fertilization of the egg or, failing that, implantation of the fertilized egg in the uterus. Believing that emergency contraception is designed to, at least in some instances, end human life, some pharmacists opposed to its use have refused to dispense it. These refusals have led, in turn, to debates over whether to protect such conscience-based choices as the free exercise of religious beliefs, or instead to require pharmacies and pharmacists to dispense with their objections as a condition of licensing.

Recently, in Stormans, Inc. v. Selecky, the Ninth Circuit overturned a preliminary injunction barring enforcement of Washington state regulations that required pharmacists to dispense emergency contraception and other drugs despite religious objections. Finding that the regulations were neutral toward religion and were generally applicable, the court held that they were subject merely to rational basis review. However, the panel erred by refusing to consider the targeting of religiously motivated behavior shown by the regulations' administrative history, and by improperly analyzing the individualized exceptions to ...

Vaiani CE. Personal conscience and the problem of moral certitude. Nurs Clin North Am. 2009 Dec;44(4):407-14. Review. PubMed PMID: 19850177.

  • Moral certainty, very simply, is knowing that you are right. The answer is a "sure thing," a foregone conclusion. Moral certainty is founded on an absolute belief to which the person is committed, without doubt. For some, religion provides moral certainty. Those who believe in religion trust that the written or spoken word and teachings of a supreme being are absolutely correct. An adherent to those teachings acts in good conscience according to those beliefs.

A look back through history is replete with examples of wars fought and injustices applied to impose or compel specific beliefs. Whether religious or ideologic, the certainty that only one's beliefs are correct and must at all costs be forced on others is alarming. Seeing the world as simply black or white, right or wrong may provide individuals reassuring certainty about their actions, but it also negates the need for critical, reflective thinking that enhances ethical practice. . .

Vanaki Z, Memarian R. Professional ethics: beyond the clinical competency. J Prof Nurs. 2009 Sep-Oct;25(5):285-91. PubMed PMID: 19751933.

  • Assessment of clinical competency in professional roles especially in crucial situations can improve the nursing profession. This qualitative research was conducted to determine the process of acquiring clinical competency by nurses in its cultural context and within the health care delivery system in Iran. This study, using grounded theory methodology, took place in universities and hospitals in Tehran. Nurses (36) included nurse managers, tutors, practitioners, and members of the Iranian Nursing Organization. Simultaneous data collection and analysis took place using participant semistructured interviews. Three categories emerged: (a) personal characteristics such as philanthropy, strong conscience, being attentive, accepting responsibility, being committed to and respecting self and others; (b) care environment including appropriate management systems, in-service training provision, employment laws, and control mechanisms, suitable and adequate equipment; and (c) provision of productive work practices including love of the profession, critical thinking, nursing knowledge, and professional expertise. Professional ethics has emerged as the core variable that embodies concepts such as commitment, responsibility, and accountability. Professional ethics guarantees clinical competency and leads to the application of specialized knowledge and skill by nurses. The results can be used to form the basis of guiding the process of acquiring clinical competency by nurses using a systematic process.

von Bergen, C.W. Conscience in the Workplace. Employee Relations Law Journal Vol. 35, No. 1, Summer, 2009 

  • A current trend in employment law is that workers feel they should be protected in the exercise of their conscience - even if doing so is contrary to their employers' wishes or to the demands of their jobs. Workers are increasingly claiming that they should be provided an unqualifi ed legal right to refuse work activities that violate their ethical, moral, personal, or religious convictions or beliefs and this assertion has become one of the more controversial issues confronting employers. After a brief review of conscientious objection, special attention is given to such objection in medically related areas, followed by a discussion of the expansion of freedom of conscience to the general workplace.

Weitz TA. What physicians need to know about the legal status of abortion in the United States. Clin Obstet Gynecol. 2009 Jun;52(2):130-9. PubMed PMID:19407519.

  • Abortion is the most politically contested social issue in the United States, a debate that manifests itself in extensive regulation of abortion as a health care service. This study provides a brief history of the judicial acceptance of abortion regulation and an overview of the most common forms of abortion regulation affecting physicians in the United States. The article concludes with a discussion of pending threats to the legal right to abortion in the United States and recommended resources where physicians can find assistance to comply with existing laws.

Yeo M. Debates: Do FPs agree on what professionalism is? No. Canadian Family Physician Vol 55: Octobre 2009

  • Dr Leong gives several examples that she believes demonstrate how "[f]amily physicians do not agree what professionalism is." I submit that these examples do not prove her argument. Essentially, professionalism pertains to the claim to competence regarding certain skills and knowledge domains and the commitment to deploy these for the primary benefi t of the patient, in keeping with the moral norms of the profession. This is pretty much what Dr Leong, glossing Pellegrino, says professionalism is. Nothing in the examples she furnishes indicates disagreement about this core idea. . .