- An ethical concern that was raised by Conway in his article
supporting the freedom to practise in accordance with conscience related
to the problems that arise when patients - specifically children - are
unable to express a considered opinion on any conflict between their
clinicians and their legal guardians about their best interests. . .
Abstract: The Perceptions of
Conscience Questionnaire (PCQ) and the Stress of Conscience
Questionnaire (SCQ) have previously been developed and validated within
the 'Stress of Conscience Study'. The aim was to revalidate these two
questionnaires, including two additional, theoretically and empirically
significant items, on a sample of healthcare personnel working in direct
contact with patients. The sample consisted of 503 healthcare personnel.
To test variation and distribution among the answers, descriptive
statistics, item analysis and principal component analysis (PCA) were
used to examine the underlying factor structure of the questionnaires.
Support for adding the new item to the PCQ was found. No support was
found for adding the new item to the SCQ. Both questionnaires can be
regarded as valid for Swedish settings but can be improved by rephrasing
some of the PCQ items and by adding items about private life to the SCQ.
- Were the views expressed by Conway and Savulescu really opposing?
I turned to those
pages with much interest, only to find that it
seemed as if they would have been in agreement, had you put the
scenarios they each describe to both of them. . .
Abstract: Abortion is the central
issue in the conscientious objection debate. In this article I
demonstrate why this is so for two philosophical viewpoints prominent in
American culture. One, represented by Patrick Lee and Robert P. George,
holds that the fundamental moral value of being human can be found in
bare life and the other, represented by Tom Beauchamp and James
Childress, holds that this fundamental value is found in the life that
can choose and determine itself. First, I articulate Lee and George's
philosophical theory and demonstrate how the fundamental moral value of
their theory, personhood, is represented in the issue of abortion.
Second, I examine Beauchamp and Childress' theoretical vision and
demonstrate how their fundamental moral value, the right to autonomous
selfdetermination, is represented in abortion. Third, I sketch the
theoretical and practical dynamics of the conscientious objection debate
as well as each author's understanding of conscience. Fourth, I
demonstrate how abortion, which represents their respective fundamental
value, shapes each perspectives' approach to the conscientious objection
debate. I conclude that because each theory finds its fundamental value
represented in the issue of abortion, each perspective is bound to
engage the conscientious objection debate in a way that centers on the
issue of abortion
Birchley G. A clear
case for conscience in healthcare practice. J Med Ethics. 2012
Jan;38(1):13-7. doi: 10.1136/jme.2011.043653. Epub 2011 Jun 27. PubMed PMID:
Abstract: The value of conscience in
healthcare ethics is widely debated. While some sources present it as an
unquestionably positive attribute, others question both the veracity of
its decisions and the effect of conscientious objection on patient
access to health care. This paper argues that the right to object
conscientiously should be broadened, subject to certain provisos, as
there are many benefits to healthcare practice in the development of the
consciences of practitioners. While effects such as the preservation of
moral integrity are widely considered to benefit practitioners, this
paper draws on the work of Hannah Arendt to offer several original
arguments in defence of conscience that may more directly benefit
patients, namely that a pang of conscience may be useful in rapidly
unfolding situations in which there is no time to reflect satisfactorily
upon activities and that, given the hierarchical nature of healthcare
institutions, a right to defy authority on the basis of conscience may
benefit junior staff who lack the institutional power to challenge the
orders of superiors.
- What Is Physician Noncompliance? I begin with a case to illustrate
the problem I examine in this article: Suppose a primary care physician
practicing in an underserved community orders a treatment for one of her
indigent patients under the state's Medicaid program. Because coverage
for this treatment was not provided under the reigning Medicaid rules,
which had recently been changed so as to exclude this, the doctor
decided to falsify her patient's condition so that he would qualify
under the revised rules. . .
Abstract: "Access" is the new
catchphrase for expanding privacy rights. This shift moves from seeking
merely legalization, to demanding government assistance and the
participation of private citizens. The trend can be seen across a
spectrum of activities such as abortion, contraception,
doctor-prescribed suicide, and reproductive technologies. Shifting from
legalization to access, however, has precipitated a variety of disputes
over the "right of conscience" of health professionals who don't want to
assist activities so defined under the right to privacy. Yet amidst this
debate, advocates for and against the right of conscience tend to adopt
some of the same, often unspoken, assumptions. Both sides tend to frame
the debate as a conflict between the rights of the doctor - protecting her
conscience - versus the right of the patient, to secure her access.
Upon closer examination, the assumption
of conflict proves to be neither accurate nor internally consistent, but a
false premise of the access position itself. This article will begin by
examining the chief access arguments being used against conscience
protections today: that the health professionals hold a monopoly so they are
bound to offer abortion, that health professionals must defer their pro-life
consciences to abortion's legal status, and that health professionals must
not impose their pro-life views. The article will conclude that, if access
principles really flowed from a neutral concern for patient choices, they
would require rather than strike down conscience protections. In many cases
patients desire in their physicians the traditional Hippocratic values that
unequivocally support human life and therefore oppose participating in
activities such as abortion. The right of patients to access such physicians
can only exist by guaranteeing the right of physicians to practice according
to those values.
Abstract: Recent survey data gathered
from British medical students reveal widespread acceptance of
conscientious objection in medicine, despite the existence of strict
policies in the UK that discourage conscientious refusals by students to
aspects of their medical training. This disconnect demonstrates a
pressing need to thoughtfully examine policies that allow conscience
objections by medical students; as it so happens, the USA is one country
that has examples of such policies. After presenting some background on
promulgated US conscience protections and reflecting on their
significance for conscience objections by medical students, this paper
observes that the dominant approach (following the American Medical
Association's conscience clause) is to allow exempted students to
instead be evaluated on the basis of alternative curricular activities
to learn the associated underlying content. This paper then introduces
and discusses an example in which male Muslim students who believe it is
wrong to touch members of the opposite sex object to performing physical
examinations on female subjects in their medical training. This sort of
case, it is argued, causes difficulty for a conscience clause that
resolves the dilemma by granting reasonable exemptions in the form of
participation in alternative curricular activities: there are cases
where one must perform the 'objectionable' activity itself in order to
learn the necessary content and underlying principles
- The Patient Protection and Affordable Care Act (ACA) requires all
health insurers and employee benefit plans to cover certain
evidence-based preventive services without cost sharing. In July 2011,
U.S. Department of Health and Human Services Secretary Kathleen Sebelius
designated contraceptive services as such preventive services. By spring
2012, the controversy regarding what types of health plan sponsors would
be able to claim an exemption from this requirement on the basis of
moral or religious objections was in full bloom. This installment of Law
and the Public's Health examines the preventive services coverage
requirement and its implications for public health.
- In a recent Opposing Views article, Conway claims that doctors
should be able to practise according to their personal values, but the
argument he uses is not persuasive. The ethical dilemma in the case is
not characterised correctly. . .
- OBJECTIVE: The purpose of this study was to assess obstetriciangynecologists'
regarding their beliefs about when pregnancy begins and to measure
characteristics that are associated with believing that pregnancy begins at
implantation rather than at conception.
STUDY DESIGN: Wemailed a
questionnaire to a stratified, random sample of 1800 practicing
obstetrician-gynecologists in the United States. The outcome of interest was
obstetrician-gynecologists' views of when pregnancy begins. Response options
were (1) at conception, (2) at implantation of the embryo, and (3) not sure.
Primary predictors were religious affiliation, the importance of religion,
and a moral objection to abortion.
RESULTS: The response rate was 66%
(1154/1760 physicians). Onehalf of US obstetrician-gynecologists (57%)
believe pregnancy begins at conception. Fewer (28%) believe it begins at implantation, and 16% are
not sure. In multivariable analysis, the consideration that religion is the
most important thing in one's life (odds ratio, 0.5; 95% confidence interval,
0.2- 0.9) and an objection to abortion (odds ratio, 0.4; 95% confidence
interval, 0.2- 0.9) were associated
independently and inversely with
believing that pregnancy begins at implantation.
Obstetrician-gynecologists' beliefs about when pregnancy begins appear to be
shaped significantly by whether they object to abortion and by the importance
of religion in their lives.
Lahl J, Rosa EC, Right of Conscience for Health-Care Providers. Linacre
Quarterly 79(2) (May 2012): 169-191.
Abstract: Health-care providers have
been challenged by changes in medical practice to include abortion,
euthanasia, and controversial fertility technologies. These procedures
go beyond saving lives, healing disease, and alleviating pain, the
traditional purposes of medicine. The foundational principles of Western
medical ethics, as characterized by the Hippocratic Oath, have been
weakened or even rejected. The consequences of abandoning the
Hippocratic tradition are illustrated by the eugenics movement, the Nazi
Holocaust, the Tuskegee experiments, and contemporary bioethics
Physicians and other health-care
personnel are under institutional and governmental pressure to succumb to
anti-Hippocratic ethics. Conscience clauses are a means of defending
medical practitioners from these trends. Characteristics of conscience
legislation that protect health-care providers are described. Strong
conscience clauses also protect the public by ensuring the survival of
healthcare personnel with shared Hippocratic values.
Abstract: Considering a growing nurse
shortage and the need for qualified nurses to handle increasingly
complex patient care situations, how ethical beliefs are influenced and
the consequences that can occur when moral conflicts of right and wrong
arise need to be explored. The aim of this study was to explore
influencers identified by nurses as having the most impact on the
development of their ethical beliefs and whether these influencers might
impact levels of moral distress and the potential for conscientious
objection. Nurses whose ethical beliefs were most influenced by their
religious beliefs scored higher in levels of moral distress and
demonstrated greater differences in areas of conscientious objection
than did nurses who developed their ethical beliefs from influencers
such as family values, life and work experience, political views or the
professional code of ethics.
Goldberg J, Jotkowitz A.
In Defense of Religious Bioethics. American Journal of
Bioethics, December, Vol. 12, No. 12, 2012
- In the first year of a celebrated graduate program in
bioethics, one of us wrote a short essay about
physician-assisted suicide that claimed that murder is not only
a breach of rights, but also a "grave affront to all human
existence as well as to He who grants life." Well, that
last part earned me a predictable scribble on the margins of my
returned paper, something to the effect of, "What if someone
does not believe in a Giver of life?"
Abstract: Studying a concept as complex
as moral distress is an ongoing challenge for those engaged in empirical
ethics research. Qualitative studies of nurses have illuminated the
experience of moral distress and widened the contours of the concept,
particularly in the area of root causes. This work has led to the
current understanding that moral distress can arise from clinical
situations, factors internal to the individual professional, and factors
present in unit cultures, the institution, and the larger health care
environment. Corley et al. (2001) was the first to publish a
quantitative measure of moral distress, and her scale has been adapted
for use by others, including studies of other disciplines (Hamric and
Blackhall; Schwenzer and Wang 2006). Other scholars have proposed
variations on Jameton's core (Sporrong et al 2006, 2007), developing
measures for related concepts such as moral sensitivity (Lutzen et
al. 2006), ethics stress (Raines 2000), and stress of conscience
(Glasberg et al. 2006). The lack of consistency and consensus on the
definition of moral distress considerably complicates efforts to study
it. Increased attention by researchers in disciplines other than nursing
has taken different forms, some problematic. Cultural differences in the
role of the nurse and understanding of actions that represent threats to
moral integrity also challenge efforts to build a cohesive
research-based understanding of the concept. In this paper, research
efforts to date are reviewed. The importance of capturing root causes of
moral distress in instruments, particularly those at unit and system
levels, to allow for interventions to be appropriately targeted is
highlighted. In addition, the issue of studying moral distress and
interaction over time with moral residue is discussed. Promising recent
work is described along with the potential these approaches open for
research that can lead to interventions to decrease moral distress.
Finally, opportunities for future research and study are identified, and
recommendations for moving the research agenda forward are offered.
crisis of conscience. Australas Psychiatry. 2012 Apr;20(2):148-52. doi:
10.1177/1039856211432462. Epub 2012 Mar 26. PubMed PMID: 22452901.
- Abstract: Objective: This paper examines the
crisis of conscience as portrayed in the biblical story of Abraham and
Isaac. Conclusion: The perspective of allegory allows
intense emotion to be contained, and placed in a socio-cultural context,
which may work against bloodshed.
[Conflicts of conscience]. Krankenpfl Soins Infirm. 2012;105(11):37.
French. PubMed PMID: 23210208.
- Abstract: Research on ethical dilemmas in health
care has become increasingly salient during the last two decades
resulting in confusion about the concept of moral distress. The aim of
the present paper is to provide an overview and a comparative analysis
of the theoretical understandings of moral distress and related
concepts. The focus is on five concepts: moral distress, moral stress,
stress of conscience, moral sensitivity and ethical climate. It is
suggested that moral distress connects mainly to a psychological
perspective; stress of conscience more to a theological-philosophical
standpoint; and moral stress mostly to a physiological perspective.
Further analysis indicates that these thoughts can be linked to the
concepts of moral sensitivity and ethical climate through a relationship
to moral agency. Moral agency comprises a moral awareness of moral
problems and moral responsibility for others. It is suggested that moral
distress may serve as a positive catalyst in exercising moral agency. An
interdisciplinary approach in research and practice broadens our
understanding of moral distress and its impact on health care personnel
and patient care.
Magelssen M. When
should conscientious objection be accepted? J Med Ethics. 2012
Jan;38(1):18-21. doi: 10.1136/jme.2011.043646. Epub 2011 Jun 20. PubMed
Abstract: This paper makes two main
claims: first, that the need to protect health professionals' moral
integrity is what grounds the right to conscientious objection in health
care; and second, that for a given claim of conscientious objection to
be acceptable to society, a certain set of criteria should be fulfilled.
The importance of moral integrity for individuals and society, including
its special role in health care, is advocated. Criteria for evaluating
the acceptability of claims to conscientious objection are outlined. The
precise content of the criteria is dictated by the two main interests
that are at stake in the dilemma of conscientious objection: the
patient's interests and the health professional's moral integrity.
Alternative criteria proposed by other authors are challenged. The bold
claim is made that conscientious objection should be recognised by
society as acceptable whenever the five main criteria of the proposed
set are met.
- Abstract: This paper examines the vexed issue of
conscientious objection and abortion. It begins by outlining the
increasing claims to conscientious objection invoked by physicians in
reproductive health services. After an examination of developments
overseas, the paper turns to the acrimonious debate in Victoria
concerning the conscience clause and the 'obligation to refer' contained
in the Abortion Law Reform Act 2008 (Vic) ('ALRA'). This paper questions
the interpretation by the Catholic Church that the clause breaches its
right to freedom of conscience and freedom of religion. We argue that
the unregulated use of conscientious objection impedes women's rights to
access safe lawful medical procedures. As such, we contend that a
physician's withdrawal from patient care on the basis of conscience must
be limited to certain circumstances. The paper then examines
international and national guidelines, international treaties and
recommendations of treaty monitoring bodies, laws in other
jurisdictions, and trends in case law. The purpose of this examination
is to show that the conscientious objection clause and the 'obligation
to refer' in ALRA is consistent with international practice and laws in
other jurisdictions. Finally, the paper turns to the problematic
interpretation of conscience and moral responsibility in the context of
abortion. We believe that narrow interpretations of conscience must be
challenged, in order to incorporate patients' rights to include the
choice of abortion and other lawful treatments according to their
conscience. We conclude that the conscientious objection provisions in
ALRA have achieved the right balance and that there is no justifiable
legal reason upon which opponents can challenge the law.
Pais P. Physicians
and their conscience. Natl Med J India. 2012 Jan-Feb;25(1):54-5. PubMed
- I read with some dismay the 'Letter from Glasgow' by H.S. Kohli.
While I am in agreement with the second part of the article about
physicians' relations with patients who have HIV or who have 'social'
conditions, the first part contains sentiments that led to the
deplorable actions of some of the medical fraternity in Nazi Germany. .
- Abstract: Caring for older persons is both
rewarding and consuming. Work with older people in Finland has been
shown to be more burdensome than in the other Nordic countries. The aim
of this study was to try out a Finnish version of the Stress of
Conscience Questionnaire (SCQ) and explore stress of conscience in staff
caring for older persons in Finland. The data were collected from the
nursing staff (n Â¼ 350) working with older people in health centre
wards, municipal and private nursing homes, and municipal and private
dementia care units in Finland. It emerged clearly from the results that
Finnish nursing staff mostly felt that they did not have enough time to
provide good care to patients, and this gave them a troubled conscience.
They also felt that the demanding work taxed their energy, a consequence
being that they could not give their own families and loved ones the
attention they would have liked.
Shaw DM, Busch J.
Rawls and religious paternalism. J Med Philos. 2012 Aug;37(4):373-86.
doi: 10.1093/jmp/jhs022. Epub 2012 Aug 21. PubMed PMID: 22914539.
- MacDougall has argued that Rawls's liberal social theory suggests
that parents who hold certain religious convictions can legitimately
refuse blood transfusion on their children's behalf. This paper
argues that this is wrong for at least five reasons. First, MacDougall
neglects the possibility that true freedom of conscience entails the
right to choose one's own religion rather than have it dictated by one's
parents. Second, he conveniently ignores the fact that children in such
situations are much more likely to die than to survive without blood.
Third, he relies on an ambiguous understanding of what is "rational" and
treats children as mere extensions of their parents. Fourth, he neglects
the fact that those in the original position would seek to protect
themselves from persecution and enslavement and thus would not allow
groups of children to be killed because of their parents' beliefs.
Finally, Rawls makes it clear that we should choose for children as we
would choose for ourselves in the original position, with no particular
conception of the good (such as that held by Jehovah's Witnesses).
- Abstract: Two hundred years ago, Thomas
Jefferson asserted that no law "ought to be dearer to man than that
which protects the rights of conscience against the enterprises of
the civil authority." Since then, freedom of conscience has
continued to be heralded as a fundamental principle of American
society. Indeed, many current policy debates--most notably in the
medical and military contexts--are predicated on the theory that
claims of conscience are worthy of legal respect. This Article,
which offers a comprehensive account of the contemporary treatment
of conscience, challenges established assumptions and seeks to
reframe the debate about the normative value of conscience in
American society. This Article first clarifies contemporary
understandings of conscience by systematically analyzing its
treatment in positive law. It looks beyond the traditional medical,
military, and religious contexts, giving a descriptive account of
law's treatment of conscience across various substantive realms,
including tax evasion, civil disobedience, discrimination, and even
violent terrorism. It demonstrates that legal accommodations are
typically granted on an ad hoc basis, without a guiding
doctrinal principle. If there is a consistent and coherent
justification for treating cases differently, our legal system has
thus far failed to provide it. This Article concludes that, in order
for American law to reflect the kind of robust, autonomy-based
respect for conscience to which every pluralistic society aspires,
we must agree on a content-neutral guiding principle for negotiating
future claims for legal accommodation. The alternative, the Article
posits, is to concede that American society has abandoned the
fundamental purpose of conscientious accommodation--namely,
protecting the individual from oppressive majoritarian
understandings of morality.
- Abstract: Objective: To explore attitudes towards
conscientious objections among medical students in the UK.
Methods: Medical students at St George's University
of London, Cardiff University, King's College London and Leeds University
were emailed a link to an anonymous online questionnaire, hosted by an
online survey company. The questionnaire contained nine questions. A total
of 733 medical students responded.
Results: Nearly half of the students in this survey
stated that they believed in the right of doctors to conscientiously object
to any procedure. Demand for the right to conscientiously object is greater
in Muslim medical students when compared with other groups of religious
Discussion: Abortion continues to be a contentious
issue among medical students and this may contribute to the looming crisis
in abortion services over the coming years. This project sheds some light on
how future doctors view some of their ethical rights and obligations.
Using empirical evidence, it reveals that conscientious objection is an
issue in the UK medical student body today. These data could help anticipate
problems that may arise when these medical students qualify and practise
medicine in the community.
Conclusion: Clearer guidance is needed for medical
students about the issue of conscientious objection at medical school.
Conscience and clinical care. Transcript, Medconference 2012.
(19-21 October, 2012) The American Association of Medicine and the Person.
Daniel P. Sulmasy
- . . . Conscience gets really misunderstood, and part of my task is
to help you think more clearly about what it is we actually talk about
when we talk about conscience. Many of us are still in some ways, are
suffering from a disservice that was done to us in grammar school, or we
never get beyond the grammar school conception of conscience. I don't
know if it translates to other cultures, but American nuns used to talk
to us about the good angel on one shoulder and the bad angel on the
other, and that was the way we were taught to think about conscience, or
as little voices that tell us what we ought to do. We somehow have this
idea that it's a sort of direct intuition of what is right and wrong,
that it just comes to everybody automatically and privately or that now,
in the era of neuroscience and neuro-ethics, that there will be a brain
center that we will find, or that will light up on a PET scan and that
will tell us the difference between right and wrong. . .
- Opinion 2.12 - Genetic Counselling: Three primary areas
of prenatal genetic testing are (1) screening or evaluating prospective
parents for genetic disease before conception to predict the likelihood of
conceiving an affected child; (2) analysis of a pre-embryo at the
preimplantation stage of artificial reproductive techniques; and (3) in
utero testing after conception, such as ultrasonography, amniocentesis,
fetoscopy, and chorionic villus sampling, to determine the condition of the
fetus. . .
- Abstract: The present study aimed at
investigating the relationship between environmental and individual
factors and Stress of Conscience among nursing staff in psychiatric
in-patient care. A questionnaire involving six different instruments
measuring Stress of Conscience, the ward atmosphere, the psychosocial
work environment, Perceived Stress, Moral Sensitivity, and Mastery was
answered by 93 nursing staff
at 12 psychiatric in-patient wards in
Sweden. The findings showed that Sense of Moral Burden, Mastery, Control
atWork and Angry and Aggressive Behavior were related to Stress of
Conscience. We conclude that Mastery and Control at Work seemed to work
as protective factors, while Sense of Moral Burden and perceptions of
Angry and Aggressive Behavior made the nursing staff more vulnerable to
Stress of Conscience. Future research should investigate whether
measures to increase the level of perceived control and being part of
decision making will decrease the level of Stress of Conscience among
- Background: Despite continuing political, legal and moral
debate on the subject, assisted suicide is permitted in only a few countries
worldwide. However, few studies have examined the impact that witnessing
assisted suicide has on the mental health of family members or close friends.
Methods: A cross-sectional survey of 85 family members or close friends who were
present at an assisted suicide was conducted in December 2007. Full or
partial Post-Traumatic Distress Disorder (PTSD; Impact of Event
Scaleâ€“Revised), depression and anxiety symptoms (Brief Symptom Inventory) and
complicated grief (Inventory of Complicated Grief) were assessed at 14 to 24
Results: Of the 85 participants, 13% met the criteria for
full PTSD (cut-off 35), 6.5% met the criteria for subthreshold PTSD (cut-off
25), and 4.9% met the criteria for complicated grief. The prevalence of
depression was 16%; the prevalence of anxiety was 6%.
Conclusion: A higher
prevalence of PTSD and depression was found in the present sample than has been
reported for the Swiss population in general. However, the prevalence of
complicated grief in the sample was comparable to that reported for the
general Swiss population. Therefore, although there seemed to be no
complications in the grief process, about 20% of respondents experienced full or
subthreshold PTSD related to the loss of a close person through assisted
- Abstract: The practice of conscientious
objection often arises in the area of individuals refusing to fulfil
compulsory military service requirements and is based on the right to
freedom of thought, conscience and religion as protected by national,
international and regional human rights law. The practice of
conscientious objection also arises in the field of health care, when
individual health care providers or institutions refuse to provide
certain health services based on religious, moral or philosophical
objections. The use of conscientious objection by health care providers
to reproductive health care services, including abortion, contraceptive
prescriptions, and prenatal tests, among other services is a growing
phenomena throughout Europe. However, despite recent progress from the
European Court of Human Rights on this issue (RR v. Poland, 2011),
countries and international and regional bodies generally have failed to
comprehensively and effectively regulate this practice, denying many
women reproductive health care services they
are legally entitled to
receive. The Italian Ministry of Health reported that in 2008 nearly 70%
of gynaecologists in Italy refuse to perform abortions on moral grounds.
It found that between 2003 and 2007 the number of gynaecologists
invoking conscientious objection in their refusal to perform an abortion
rose from 58.7 percent to 69.2 percent. Italy is not alone in Europe,
for example, the practice is prevalent in Poland, Slovakia, and is
growing in the United Kingdom. This article outlines the international
and regional human rights obligations and medical standards on this
issue, and highlights some of
the main gaps in these standards. It
illustrates how European countries regulate or fail to regulate
conscientious objection and how these regulations are working in
practice, including examples of jurisprudence from national level courts
and cases before the European Court of Human Rights. Finally, the
article will provide recommendations to national governments as well as
to international and regional bodies on how to regulate conscientious
objection so as to both respect the practice of conscientious objection
while protecting individual's right to reproductive health care.