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Protection of Conscience Project

Service, not Servitude
Periodicals & Papers


Altuntas S, Baykal U. Relationship between nurses' organizational trust levels and their organizational citizenship behaviors. J Nurs Scholarsh. 2010 Jun;42(2):186-94. PubMed PMID: 20618602.

  • Abstract: Purpose: This research used a descriptive and explorative design to determine the levels of nurses' organizational trust and organizational citizenship and to investigate relationships between the levels of organizational trust and organizational citizenship behaviors.

Design and Methods: Nurses who had completed their orientation from a total of 11 hospitals with bed capacities of 100 and located in the European district of Istanbul were included in the sample for this study. Formal, written applications and approval of the ethical committee were obtained from concerned institutions before proceeding with the data collection step. The Organizational Trust Inventory and the Organizational Citizenship Level Scale, a questionnaire form including five questions regarding nurses' personal characteristics, were used in data collection. Data collection tools were distributed to 900 nurses in total, and usable data were obtained from 482 nurses. Number and percentage calculations and Pearson correlation analysis were used to assess research data.

Findings: The results of the present research showed that nurses had a higher than average level of trust in their managers and coworkers and they trusted more in their managers and coworkers than their institutions. The Organizational Citizenship Level Scale indicated that the behavior most frequently demonstrated by the nurses was conscientiousness, followed by courtesy and civic virtue, whereas sportsmanship was displayed to an average extent. An analysis of relationships between nurses' level of organizational trust and their organizational citizenship behaviors revealed that nurses who trust in their managers, institutions, and coworkers demonstrated the organizational citizenship behaviors of conscientiousness, civic virtue, courtesy, and altruism more frequently.

Conclusions: The findings attained in this study indicated that the organizational trust the staff had in their institutions, managers, and coworkers influenced the organizational citizenship behaviors of conscientiousness, civic virtue, altruism, and courtesy, whereas it had no effect on sportsmanship behavior. Nurse managers should introduce studies to improve their subordinates' organizational trust to ensure that they develop organizational citizenship behaviors, and they should support them in this process.

Clinical Relevance: These topics for nursing services will provide guidance to managers, particularly to managers of nursing services, in establishing processes to predict nurses' organizational commitment, job satisfaction, performance, intention to leave, and other relevant issues.

Arneson RJ. Against freedom of conscience. 47 San Diego L. Rev. 1015 2010

  • Introduction: Is there a moral right to freedom of conscience? Should a legal right to freedom of conscience be established in each country on Earth? This essay argues for negative answers to both questions. 

The term freedom of conscience might refer to freedom of thought and the freedom of expression that sustains freedom of thought. In this sense we might affirm the right of each person to form individual opinions about the right and the good, about what we owe one another by way of due consideration of others, and about what is worthy of pursuit in life, on the basis of free discussion of these matters. In the present discussion, these freedoms, important as they might be, are not under consideration. Let us assume freedom of thought and expression are secured. The status of freedom of conscience in the sense that is our concern in this discussion is still wide open. . .

Ayala FJ. Colloquium paper: the difference of being human: morality. Proc Natl Acad Sci U S A. 2010 May 11;107 Suppl 2:9015-22. Epub 2010 May 5. PubMed PMID: 20445091; PubMed Central PMCID: PMC3024030.

  • In The Descent of Man, and Selection in Relation to Sex, published in 1871, Charles Darwin wrote: "I fully . . . subscribe to the judgment of those writers who maintain that of all the differences between man and the lower animals the moral sense or conscience is by far the most important." I raise the question of whether morality is biologically or culturally determined. The question of whether the moral sense is biologically determined may refer either to the capacity for ethics (i.e., the proclivity to judge human actions as either right or wrong), or to the moral norms accepted by human beings for guiding their actions. I propose that the capacity for ethics is a necessary attribute of human nature, whereas moral codes are products of cultural evolution. Humans have a moral sense because their biological makeup determines the presence of three necessary conditions for ethical behavior: (i) the ability to anticipate the consequences of one's own actions; (ii) the ability to make value judgments; and (iii) the ability to choose between alternative courses of action. Ethical behavior came about in evolution not because it is adaptive in itself but as a necessary consequence of man's eminent intellectual abilities, which are an attribute directly promoted by natural selection. That is, morality evolved as an exaptation, not as an adaptation. Moral codes, however, are outcomes of cultural evolution, which accounts for the diversity of cultural norms among populations and for their evolution through time.

Azria E. [Statement of conscience in trisomy 21 screening: pregnant women's free will jeopardized]. J Gynecol Obstet Biol Reprod (Paris). 2010 Nov;39(7):592-4. French. PubMed PMID: 20926207.


Albert Márquez M. [Freedom of conscience. Biojuridical conflicts at multicultural societies]. Cuad Bioet. 2010 Jan-Apr; 21(71):61-77. Spanish. PubMed PMID: 20405974.


Charlton BG. First and second things, and the operations of conscience in science. Med Hypotheses. 2010 Jan;74(1):1-3. Epub 2009 Sep 5. PubMed PMID: 19733980.

  • Why is modern science less efficient than it used to be, why has revolutionary science declined, and why has science become so dishonest? One plausible explanation behind these observations comes from an essay First and second things published by CS Lewis. First Things are the goals that are given priority as the primary and ultimate aim in life. Second Things are subordinate goals or aims – which are justified in terms of the extent to which they assist in pursuing First Things. The classic First Thing in human society is some kind of religious or philosophical world view. Lewis regarded it as a 'universal law' that the pursuit of a Second Thing as if it was a First Thing led inevitably to the loss of that Second Thing: 'You can't get second things by putting them first; you can get second things only by putting first things first'. 

I would argue that the pursuit of science as a primary value will lead to the loss of science, because science is properly a Second Thing. Because when science is conceptualized as a First Thing the bottom-line or operational definition of 'correct behaviour' is approval and high status within the scientific community. However, this does nothing whatsoever to prevent science drifting-away from its proper function; and once science has drifted then the prevailing peer consensus will tend to maintain this state of corruption.

I am saying that science is a Second Thing, and ought to be subordinate to the First Thing of transcendental truth. Truth impinges on scientific practice in the form of individual conscience (noting that, of course, the strength and validity of conscience varies between scientists). When the senior scientists, whose role is to uphold standards, fail to posses or respond-to informed conscience, science will inevitably go rotten from the head downwards. What, then, motivates a scientist to act upon conscience? I believe it requires a fundamental conviction of the reality and importance of truth as an essential part of the basic purpose and meaning of life. Without some such bedrock moral underpinning, there is little possibility that individual scientific conscience would ever have a chance of holding-out against an insidious drift toward corruption enforced by peer consensus.

Cotterrell R. Conscientious objection to assigned work tasks: A comment on relations of law and culture. Queen Mary University of London, School of Law Legal Studies Research Paper No. 104/2012.  Comparative Labor Law & Policy Journal, volume 31 (2010), 511-22

  • This paper considers how far a legal-cultural perspective may help to explain contrasts in approaches, in different jurisdictions, to a particular legal issue addressed by five national reports on which the paper comments. The issue is: how should law respond to employees' objections, on grounds of conscience, to being required to perform particular work tasks assigned by their employers, or to being required to perform them in particular ways? The national reports discussed relate to Japan, the United States, Germany, Israel and Spain. The paper argues that cultural factors can influence not only law's response but also the ways in which the issue of conscience is understood, contextualised and legally presented.

Davidson LA, Pettis CT, Joiner AJ, Cook DM, Klugman CM. Religion and conscientious objection: a survey of pharmacists' willingness to dispense medications. Soc Sci Med. 2010 Jul;71(1):161-5. Epub 2010 Apr 13. PubMed PMID: 20447746

  • Abstract: Some US states allow pharmacists to refuse to dispense medications to which they have moral objections, and federal rules for all health care providers are in development. This study examines whether demographics such as age, religion, gender influence 668 Nevada pharmacists' willingness to dispense or transfer five potentially controversial medications to patients 18 years and older: emergency contraception, medical abortifacients, erectile dysfunction medications, oral contraceptives, and infertilitymedications. Almost 6% of pharmacists indicated that they would refuse to dispense and refuse to transfer at least one of these medications.  Religious affiliation significantly predicted pharmacists' willingness to dispense emergency contraception and medical abortifacients, while age significantly predicted pharmacists' willingness to distribute infertility medications.  Evangelical Protestants, Catholics and other-religious pharmacists were significantly more likely to refuse to dispense at least one medication in comparison to non-religious pharmacists in multinomial logistic regression analyses.  Awareness of the influence of religion in the provision of pharmacy services should inform health care policies that appropriately balance the rights of patients, physicians, and pharmacists alike.  The results from Nevada pharmacists may suggest similar tendencies among other health care workers, who may be given latitude to consider morality and value systems when making clinical decisions about care.

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 ofdignified  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.

Diniz D. Conscientious objection in developing countries. Dev World Bioeth. 2010 Apr;10(1):ii. PubMed PMID: 20433463.

  • The administration of former President George W. Bush and the subsequent revival of the abortion disputes in the United States have put the ethical challenges of conscientious objection in the spotlight in many international journals on bioethics in the last decade. Bioethical analyses cover a wide range of perspectives: from bedside ethics between women and physicians, to constitutional analyses of how to protect fundamental needs in the context of pluralist societies.  In the last few years some clear administrative guidelines have been drawn up, considering the institutional realities of developed countries, most of them with private healthcare systems. These include rules that the objection or refusal is an individual right and not an institutional right and healthcare providers have a duty to refer a woman to a similar health care service provider.

I would suggest that this is not the reality for many developing countries . . .

Farris KB, Ashwood D, McIntosh J, DiPietro NA, Maderas NM, Landau SC, Swegle J, Solemani O. Preventing unintended pregnancy: pharmacists' roles in practice and policy via partnerships. J Am Pharm Assoc (2003). 2010 Sep-Oct;50(5):604-12. Review. PubMed PMID: 20833619.

  • Abstract:  Objectives: To review the literature regarding pharmacists' roles in preventing unintended pregnancy, review the relevant laws and policies in the United States to describe pharmacists' and/or pharmacy's role in policy development related to unintended pregnancy, and identify partners who pharmacists can work with in this public health area.

Data sources: A systematic review was conducted focusing on the role of pharmacists in unintended pregnancy. For practice, articles were identified in Medline through July 1, 2009, using MeSH and keywords. For policy, two authors examined the current status of access issues related to over-the-counter (OTC) status and collaborative practice agreements. Partners were identified in the reviews and authors' experiences.

Data extraction: English-language, U.S.-based articles that contained either qualitative or quantitative data or were review articles addressing pharmacist interventions, pharmacists' knowledge and attitudes regarding contraception, and pharmacists' comfort and ability to counsel on preventing unintended pregnancy were included.

Data synthesis: Some improvements to emergency contraception (EC) access in pharmacies have occurred during the previous decade. Studies focused on counseling, pharmacist provision of depot reinjection, and pharmacist initiation of oral contraceptives were positive. No studies linked increased contraceptive access in pharmacies to lower pregnancy rates. In terms of policy, the literature described three access-related areas, including (1) EC and conscience clauses, (2) collaborative practice agreements, and (3) changes in prescription to OTC status. Pharmacists' partnerships may include physicians/clinicians, local health departments, family planning organizations, nongovernmental organizations, and colleges of pharmacy.

Conclusion: Currently, pharmacists may increase access to contraceptives primarily via EC and use of collaborative practice agreements to initiate and/or continue hormonal contraceptives. New practice models should be implemented in community or clinic practices as allowed by collaborative practice regulations in each state. We encourage researchers and practitioners to consider a community approach in their endeavors by working with numerous types of primary care providers and organizations to explore ways to increase contraceptive access.

Goffin T. The physician's right to conscientious objection: an evolving recognition in Europe. Med Law. 2010 Jun;29(2):227-37.

  • Abstract: Due to the growing number of medical treatments, physicians - who are also human beings with their own conscience and beliefs - are increasingly confronted with treatments that may conflict with their principles and convictions. Although several human rights documents recognize the freedom of conscience and belief, we could not locate the recognition of an explicit right to conscientious objection. Furthermore, a direct application of the right to freedom of thought, conscience and religion, as recognized by article 9 of the ECHR, does not include such a right due to the narrow interpretation of this right by the European Court of Human Rights. However, the Court seems to have taken steps away from this narrow interpretation in Pichón and Sajous v. France. Notwithstanding these steps, no general right to conscientious objection exists. Physicians therefore are dependent on a judgment if they refuse a certain treatment because of conscientious objections.

Gold A. Physicians' "right of conscience"- beyond politics. J Law Med Ethics. 2010 Spring;38(1):134-42. PubMed PMID: 20446991.

  • Introduction: Recently, the discussion regarding the physicians' "Right of Conscience" (ROC) has been on the rise. This issue is often confined to the "reproductive health" arena (abortions, birth control, morning-after pills, fertility treatments, etc.) within the political context. The recent dispute of the Bush-Obama administrations regarding the legal protections of health workers who refuse to provide care that violates their personal beliefs is an example of the political aspects of this dispute. . .

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.