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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Díez Fernández JA. [Patients' autonomy and doctors' duties according to the Andalusian bill of "dignified dead"]. Cuad Bioet. 2010 Jan-Apr;21(71):51-60. Spanish. PubMed PMID:  20405973.

  • Abstract: The provisions of the andalusian Law on rights and guarantees of the dignity of persons in the process of death, also known as«act of dignified  death», are based on two pillars: The right to the autonomy of the patient, supported, if it be, in a will expressed in instructions given in advance and the duties of doctors and health centers to give satisfaction, to the extent of their potential and respecting the law, those demands. The core of the question is to find the point of necessary balance between the wishes of the patient and the freedom and responsibility of the doctor.

Together with positive aspects, such as the recognition of the right and the implementation of the palliative care, there are other questionable proposals, affecting the rights of doctors: a lack of understanding of freedom and professional responsibility, recognition of the objection of conscience and certain ethics duties, etc. As expressed by the law, remain committed  substantial rights of doctors and might favor, in the care activity, introducing practices of defensive medicine.

Gustafsson G, Eriksson S, Strandberg G, Norberg A. Burnout and perceptions of conscience among health care personnel: a pilot study. Nurs Ethics. 2010 Jan;17(1):23-38. PubMed PMID: 20089623.

  • Abstract:  Although organizational and situational factors have been found to predict burnout, not everyone employed at the same workplace develops it, suggesting that becoming burnt out is a complex, multifaceted phenomenon. The aim of this study was to elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among two groups of health care personnel from the same workplaces, one group on sick leave owing to medically assessed burnout (n ¼ 20) and one group who showed no indications of burnout (n ¼ 20). The results showed that higher levels of stress of conscience, a perception of conscience as a burden, having to deaden one's conscience in order to keep working in health care and perceiving a lack of support characterized the burnout group. Lower levels of stress of conscience, looking on life with forbearance, a perception of conscience as an asset and perceiving support from organizations and those around them (social support) characterized the nonburnout group.

Hanami T. Conscientious objection in Japan.(employees' right to refuse and perform a certain work that is objectionable from his conviction) 31 Comp. Lab. L. & Pol'y J. 441 2009-2010

  • The History: After the Second World War, Japan's national flag ("Hinomaru," meaning "rising sun") and national anthem ("Kimigayo") have been two of the most controversial issues in Japanese politics. Leftist groups have attacked both as symbols of the militarism that resulted in the invasion of Japan during the war. Throughout the entire history of post-war Japan, such groups have taken advantage of every opportunity to protest singing the anthem or paying respect to the flag. The Japan Teachers Union, which organizes public school teachers, once was dominated by the Japan Communist Party and, as it has been for a long time and continues today, is still heavily influenced by leftist ideology. The union has been organizing protests at school events such as entrance, graduation, and other ceremonies and union members have further refused to pay respect to the flag or sing the national anthem. . .

Hanssen I, Alpers LM. Utilitarian and common-sense morality discussions in intercultural nursing practice. Nurs Ethics. 2010 Mar;17(2):201-11. PubMed PMID: 20185444.

  • Abstract:  Two areas of ethical conflict in intercultural nursing – who needs single rooms more, and how far should nurses go to comply with ethnic minority patients' wishes? – are discussed from a utilitarian and commonsense morality point of view. These theories may mirror nurses' way of thinking better than principled ethics, and both philosophies play a significant role in shaping nurses' decision making. Questions concerning room allocation, noisy behaviour, and demands that nurses are unprepared or unequipped for may be hard to cope with owing to physical restrictions and other patients' needs. Unsolvable problems may cause stress and a bad conscience as no solution is 'right' for all the patients concerned. Nurses experience a moral state of disequilibrium, which occurs when they feel responsible for the outcomes of their actions in situations that have no clear-cut solution.

Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care. J Adv Nurs. 2010 Aug;66(8):1708-18. Epub 2010 Jun 16. PubMed PMID: 20557396.

  • Abstract:  Aim. This paper is a report of a study of patterns of perceptions of conscience, stress of conscience and burnout in relation to occupational belonging among Registered Nurses and nursing assistants in municipal residential care of older people.

Background. Stress and burnout among healthcare personnel and experiences of ethical difficulties are associated with troubled conscience. In elder care the experience of a troubled conscience seems to be connected to occupational role, but little is known about how Registered Nurses and nursing assistants perceive their conscience, stress of conscience and burnout.

Method. Results of previous analyses of data collected in 2003, where 50 Registered Nurses and 96 nursing assistants completed the Perceptions of Conscience Questionnaire, Stress of Conscience Questionnaire and Maslach Burnout Inventory, led to a request for further analysis. In this study Partial Least Square Regression was used to detect statistical predictive patterns.

Result. Perceptions of conscience and stress of conscience explained 41Æ9% of the variance in occupational belonging. A statistical predictive pattern for Registered Nurses was stress of conscience in relation to falling short of expectations and demands and to perception of conscience as demanding sensitivity. A statistical predictive pattern for nursing assistants was perceptions that conscience is an authority and an asset in their work. Burnout did not contribute to the explained variance in occupational belonging.

Conclusion. Both occupational groups viewed conscience as an asset and not a burden. Registered Nurses seemed to exhibit sensitivity to expectations and demands and nursing assistants used their conscience as a source of guidance in their work. Structured group supervision with personnel from different occupations is needed so that staff can gain better understanding about their own occupational situation as well as the situation of other occupational groups.

Juthberg C, Sundin K. Registered nurses' and nurse assistants' lived experience of troubled conscience in their work in elderly care--a phenomenological hermeneutic study. Int J Nurs Stud. 2010 Jan;47(1):20-9. Epub 2009 Jul 1. PubMed PMID: 19573872.

  • Abstract: Background: In elderly care registered nurses (RNs) and nurse assistants (NAs) face ethical challenges which may trouble their conscience.

Objective: This study aimed to illuminate meanings of RNs' and NAs' lived experience of troubled conscience in their work in municipal residential elderly care.

Design: Interviews with six RNs and six NAs were interpreted separately using a phenomenological hermeneutic method.

Settings: Data was collected in 2005 among RNs and NAs working in special types of housings for the elderly in a municipality in Sweden.

Participants: The RNs and NAs were selected for participation had previously participated in a questionnaire study and their ratings in the questionnaire study constituted the selection criteria for the interview study.

Results: The RNs' lived experience of troubled conscience was formulated in two themes. The first theme is 'being trapped in powerlessness' which includes three sub-themes: being restrained by others' omission, being trapped in ethically demanding situations and failing to live up to others' expectations. The second theme is 'being inadequate' which includes two sub-themes: lacking courage to maintain one's opinion and feeling incompetent. The NAs' lived experience of troubled conscience was formulated in the two themes. The first is 'being hindered by pre-determined conditions' which includes two sub-themes: suffering from lack of focus in one's work and being restrained by the organisation. The second theme is 'being inadequate' which includes two sub-themes: lacking the courage to object and being negligent.

Conclusions: The RNs' lived experience of troubled conscience were feelings of being trapped in a state of powerlessness, caught in a struggle between responsibility and authority and a sense of inadequacy fuelled by feelings of incompetence, a lack of courage and a fear of revealing themselves and endangering residents' well-being. The NAs' lived experience of troubled conscience was feelings of being hindered by pre-determined conditions, facing a fragmented work situation hovering between norms and rules and convictions of their conscience. To not endangering the atmosphere in the work-team they are submissive to the norms of their co-workers. They felt inadequate as they should be model care providers. The findings were interpreted in the light of Fromm's authoritarian and humanistic conscience.

Kagan PN, Smith MC, Cowling WR 3rd, Chinn PL. A nursing manifesto: an emancipatory call for knowledge development, conscience, and praxis. Nurs Philos. 2010 Jan;11(1):67-84. PubMed PMID: 20017884.

  • Abstract:  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.

Kolber AJ.  Alternative Burdens on Freedom of Conscience.  47 San Diego L. Rev. 919 (2010)

  • Introduction: Suppose a pharmacist refuses to dispense pills that induce abortion claiming that dispensing such pills runs counter to principles he holds dear. Indeed, the pharmacist claims that forcing him to dispense the pills would violate his freedom of conscience. He even claims that he would not have become a pharmacist had he foreseen an obligation to dispense such pills at the time he entered the profession. Should the pharmacist's job be protected if he is making a bona fide claim of conscience? And does it matter whether the pharmacist's objection to dispensing the pills is rooted in religious or nonreligious reasons?

Martínez León M, Rabadán Jiménez J. [Conscientious objection for health professionals in ethics and deontology]. Cuad Bioet. 2010 May-Aug;21(72):199-210. Spanish. PubMed PMID: 20886912.


McLeod C. An institutional solution to conflicts of conscience in medicine. Hastings Cent Rep. 2010 Nov-Dec;40(6):41-2. PubMed PMID: 21140744.

  • One of the most intriguing questions in medical ethics is whether individual physicians ought to be able to refuse conscientiously to provide services that patients seek. The issue requires us to delve into difficult problems, such as the extent to which physicians must subordinate their interests to those of their current or prospective patients, and how essential the services physicians object to are as new medical technologies develop. Despite the difficulty that surrounds this issue, many bioethicists - like Dan Brock and Mark Wicclair - have tried to address it in a single journal article. But Holly Fernandez Lynch is an exception. She gives conscientious objection in medicine (hereafter, "conscientious objection") the book-length treatment that it deserves. . .

Monedero P, Navia J. [Limiting therapeutic intervention and euthanasia: making decisions and resolving conflicts in end-of-life-care]. Rev Esp Anestesiol Reanim. 2010 Nov;57(9):586-93. Review. Spanish. PubMed PMID: 21155340.

Moss K. "Do No Harm" - unless she wants an abortion or birth control: the conscience movement's impact on women's health. 19 Tex. J. Women & L. 173 2009-2010

  • Introduction: Even in the dire circumstances of rape, incest, or medical emergency, certain federal and state provisions allow health care professionals to ignore the needs of women on the basis of ethical and moral qualms, also known as conscientious refusal. Conscience has been defined as the private, constant, ethically attuned part of the human character. It operates as an internal sanction that comes into play through critical reflection about a certain action or inaction.' With the protection of certain federal and state regulations, doctors, who vow under the Hippocratic Oath to do no harm, may turn their patients away withoutreferrals to other doctors willing to perform abortions. This legal protection of conscience extends beyond doctors, and also exculpates pharmacists from liability when they refuse to fill prescriptions for birth control pills or Plan B emergency contraceptives. This paper seeks to analyze the basis of the laws protecting conscientious objection in healthcare and to examine how the legal protection of this behavior conflicts with the rights and welfare of women. . .

Murray JS.  Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk.  OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Manuscript 2. DOI:  10.3912/OJIN.Vol15No03Man02

  • Abstract: Healthcare professionals often face complex ethical dilemmas in the workplace. Some professionals confront the ethical issues directly while others turn away. Moral courage helps individuals to address ethical issues and take action when doing the right thing is not easy. In this article the author defines moral courage, describes ongoing discussions related to moral courage, explains how to recognize moral courage, and offers strategies for developing and demonstrating moral courage when faced with ethical challenges.

Pope TM. Legal briefing: conscience clauses and conscientious refusal. J Clin Ethics. 2010 Summer; 21(2):163-76. PubMed PMID: 20866024.

  • Abstract: This issue's "Legal Briefing" column covers legal developments pertaining to conscience clauses and conscientious refusal.  Not only has this topic been the subject of recent articles in this journal, but it has also been the subject of numerous public and professional discussions. Over the past several months, conscientious refusal disputes have had an unusually high profile not only in courthouses, but also in legislative and regulatory halls across the United States.  Healthcare providers' own moral beliefs have been obstructing and are expected to increasingly obstruct patients' access to medical services. For example, some providers, on ethical or moral grounds, have denied: (1) sterilization procedures to pregnant patients, (2) pain medications in end-of-life situations, and (3) information about emergency contraception to rape victims. On the other hand, many healthcare providers have been forced to provide medical treatment that is inconsistent with their moral beliefs. There are two fundamental types of conscientious objection laws. First, there are laws that permit healthcare workers to refuse providing - on ethical, moral, or religious grounds healthcare services that they might otherwise have a legal or employer-mandated obligation to provide.  Second, there are laws directed at forcing healthcare workers to provide services to which they might have ethical, moral, or religious objections.

Both types of laws are rarely comprehensive, but instead target: (1) certain types of healthcare providers, (2) specific categories of healthcare services, (3) specific patient circumstances, and (4) certain conditions under which a right or obligation is triggered. For the sake of clarity, I have grouped recent legal developments concerning conscientious refusal into eight categories:

1. Abortion: right to refuse
2. Abortion: duty to provide
3. Contraception: right to refuse
4. Contraception: duty to provide
5. Sterilization: right to refuse
6. Fertility, HIV, vaccines, counseling
7. End-of-life measures: right to refuse
8. Comprehensive laws: right to refuse.

Range LM, Rotherham AL. Moral distress among nursing and non-nursing students. Nurs Ethics 2010 17: 225 DOI: 10.1177/0969733009352071

  • Abstract: Their nursing experience and/or training may lead students preparing for the nursing profession to have less moral distress and more favorable attitudes towards a hastened death compared with those preparing for other fields of study. To ascertain if this was true, 66 undergraduates (54 women, 9 men, 3 not stated) in southeastern USA completed measures of moral distress and attitudes towards hastening death. Unexpectedly, the results from nursing and non-nursing majors were not significantly different. All the present students reported moderate moral distress and strong resistance to any efforts to hasten death but these factors were not significantly correlated. However, in the small sample of nurses in training, the results suggest that hastened death situations may not be a prime reason for moral distress.

Reid-Searl K, Moxham L, Walker S, Happell B. "Whatever it takes": nursing students' experiences of administering medication in the clinical setting. Qual Health Res. 2010 Jul;20(7):952-65. Epub 2010 Apr 19. PubMed PMID: 20404361.

  • Abstract:  This research was conducted to examine experiences of nursing students in administering medication in the clinical setting. Grounded theory was utilized, involving in-depth interviews with 28 final-year students. In this article, we examine the importance participants attached to conforming to the prevailing culture, and their responses when offered what they considered inadequate supervision. Three main categories emerged: norming for the survival of self, conforming and adapting for benefit of self and others; and performing with absolute conscience. Subsequently, the model of contingent reasoning was developed to explain the actions of students. Contingent reasoning was influenced by the relationship with the registered nurse and individual characteristics of the students. Contingent reasoning was validated by participants and is discussed in relation to Kohlberg's theory of moral reasoning and other relevant nursing literature. This model has the potential to enhance understanding of how students make decisions, and ultimately to positively influence this process.

Slovinska S.  Comparative legal analysis of conscientious objections in health care.  LL.M. Short Thesis.  Course: Patient's Rights in the Twenty First Century.  Professor: Judit Marcella Sándor.  Central European University, Budapest, Hungary. 29 March, 2010

  • The purpose of this thesis is to demonstrate what would be an appropriate model of the regulation of conscientious objections in health care. These objections are regulated in many countries' national legislations, however, some of them fail to provide safeguards which would secure proper balance between the two conflicting interests - the health care professional's right to act in accordance with his conscience and individual's right to access health care.

Therefore, this thesis analyzes regulation of the conscientious objection in the legal systems of the USA, the UK and the Slovak Republic with respect to the appropriateness of such regulation and major differences which they include. The thesis suggests that the protection of conscientious objection in the USA can go too far and be too excessive, while the UK presents much more appropriate model of regulation of conscientious objection with certain limitations. Furthermore, it submits that regulation of conscientious objection in Slovakia consists in general but vague clause creating the possibilities for future controversies.

The thesis also analyses different opinions on the acceptability of conscientious objection in health care and finally, it suggests conditions and limitations of conscientious objection that should be met in the regulation of national legislations in order to find appropriate balance between the competing interests of health care professionals and patient.

Sutton EJ, Upshur RE. Are there different spheres of conscience? J Eval Clin Pract. 2010 Apr;16(2): 338-43. PubMed PMID: 20367861.

  • Abstract:  Interest in understanding the meaning of conscience and conscientious objection in medicine has recently emerged in the academic literature. We would like to contribute to this debate in four ways: (1) to underscore and challenge the existing hierarchy of conscientious objection in health care; (2) to highlight the importance of considering the lay public when discussing the role of conscientious objection in medicine; (3) to critique the numerous proposals put forth in favour of implementing review boards to assess whether appeals to conscience are justifiable, reasonable and sincere; and (4) to introduce the Universal Declaration of Human Rights and the Siracusa Principles into the dialogue around conscience and suggest that perhaps conscientious objection is a human right.

Tettelbach CA. Practice against our beliefs. J Christ Nurs. 2010 Apr-Jun;27(2):106-9. PubMed PMID: 20364524.

  • Hans's descent started gradually. Shortly after joining the Army, his superior gave him the task of registering a group of people."For their protection,"the sergeant told him. A few months later, the sergeant ordered him to gather the people together and deliver them to a certain walled-in section of the city."For their protection," he said again. Later, Hans was part of a detail that escorted those people to waiting trains. They were traveling to another city for work. Rumors of extermination surfaced, and people described Jews as "vermin." By the time Hans was transferred a concentration camp, he was hardened to the fate of the Jews.  As Hans descended into his killer role, the people in authority rewarded him for obedience and threatened to shoot him if he protested. The soldiers who got promoted were the most brutal and ruthless in carrying out orders. . .

von Cranach M. Ethics in psychiatry: the lessons we learn from Nazi psychiatry. Eur Arch Psychiatry Clin Neurosci. 2010 Nov;260 Suppl 2:S152-6. Epub 2010 Oct 20. Review. PubMed PMID: 20960004.

  • Abstract: Under the Euthanasia Program of Nazi Germany, more than 200,000 psychiatric patients were killed by doctors in psychiatric institutions. After summarising the historical facts and the slow and still going-on process of illuminating and understanding what happened, some ethical consequences are drawn. What can we learn from history? The following aspects are addressed: the special situation of psychiatry in times of war, bioethics and biopolitics, the responsibility of the psychiatrist for the individual patient, the effects of hierarchy on personal conscience and responsibility, the unethical  "curableuncurable" distinction and the atrocious concept that persons differ in their value.

Watson K. The unacknowledged consensus on abortion. Am J Bioeth. 2010 Dec;10(12):57-9. PubMed PMID: 21161849.

  • Bertha Alvarez Manninen's (2010) exploration of how a bodily integrity argument might defend the abortion right even if the Supreme Court assigned fetuses to the category of persons for purposes of constitutional law has many strengths.  As a bioethicist and a legal scholar, I share both her desire to bridge philosophical and legal conversations and her conclusion that the abortion right should be preserved.  In this brief commentary, I offer alternate responses to the two factors driving her project (legislative challenges to Roe and perceptions of the pro-choice position as "callous") and raise two unanswered questions in her bodily integrity argument.

Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics. 2010 Winter;19(1):38-50. PubMed PMID: 20025801.

  • Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities. In 1996, the Medical Student Section of the American Medical Association (AMA) introduced a resolution calling on the AMA to adopt a policy in support of exemptions for students with ethical or religious objections.  In that report, students identified abortion, sterilization, and procedures performed on animals as examples of activities that might prompt requests for conscience-based exemptions (CBEs). In response to the student initiative, the Council on Medical Education recommended the adoption of seven "principles to guide exemption of medical students from activities based on conscience." The House of Delegates adopted these principles in their entirety.