Update on American HHS birth control mandate controversy: March, 2013

A judge of the St. Louis Federal District Court struck down parts of a Missouri law  ensuring freedom of conscience for those objecting to paying for contraceptive coverage and abortion drugs in their health plans. [St. Louis Review]  To date, 10 amicus curiae briefs have been filed by Americans United for Life in support of lawsuits against the U.S. federal government regulation that requires objecting business owners to provide health insurance coverage for contraceptives, embryocides, and surgical sterilization. [AUL news release]   The chairman of the U.S. Conference of Catholic Bishops (USCCB) Committee on Pro-Life Activities,has asked members of the U.S. House of Representatives to support the Health Care Conscience Rights Act of 2013.H.R. 940, which includes provisions to prevent objecting businesses or individuals from being forced to provide  health insurance coverage for contraceptives, embryocides, and surgical sterilization. [USCCB news release]  Attorneys General of 13 states (Ohio, Alabama, Colorado, Florida, Georgia, Idaho, Kansas, Montana, Nebraska, Oklahoma, South Carolina, Texas and West Virginia) have written to the federal government asking that the proposed exemptions for objectors to the regulation be broadened to include private employers. [Columbus Dispatch].  More than 147,000 people and groups have made formal comments about the proposed regulation, 30 times more than the comments made on the next most-commented-upon rule. [The Hill]  Meanwhile, the U.S. Senate, which is controlled by the Democratic Party, voted down a measure that would have stopped funding for enforcment of the regulation.



Group claims Maltese abortion law violates convention against torture

The International Commission of Jurists (ICJ) has submitted a report to the UN Human Rights Council that accuses Malta of violating the Convention Against Torture and other alleged obligations because Maltese law prohibits abortion.  The ICJ describes itself as “60 eminent judges and lawyers from all regions of the world” that “promotes and protects human rights through the Rule of Law, by using its unique legal expertise to develop and strengthen national and international justice systems.”  The same general claim was made this month by the UN Human Rights Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment.


Freedom of conscience and health care in the United States of America

Conflict Between Public Health and Religious Liberty in the Patient Protection and Affordable Care Act

Peter West-Oram

Health Care Anal. 2013 Mar 29. [Epub  ahead of print] PubMed PMID: 23539432.


The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties. [Full Text]

Australian physicians unwilling to provide late term psychosocial abortions

A former health services commissioner who was among those behind the passage of a controversial abortion law in the State of Victoria is complaining that the law is “being thwarted at the service provision level.”  Her concern focuses on women seeking late term abortions – apparently 16 through 24 weeks gestation and beyond.  Physicians are reported to be willing to provide late term abortions only for eugenic reasons, but about 70 women annually ask for late term abortions for “psychosocial reasons.”  Another factor reducing availability appears to be the need to give priority to devote health care resources to addressing illness and other health problems over “psychosocial” issues.  One clinical advisor has suggested that this could be rectified by a regulation requiring that abortion be given legal priority. [The Age]

Institutional conscience and access to services: can we have both?

Cameron Flynn, Robin Fretwell Wilson

Virtual Mentor. 2013 Mar 1;15(3):226-35. doi: 10.1001/virtualmentor.2013.15.3.pfor1-1303. PubMed PMID: 23472813

It appears, at times, that health care and religion do not mix. Consider the sterilization and contraception coverage mandate under the Patient Protection and Affordable Care Act. The mandate requires nearly all employers and health insurers to cover as “essential health care services” certain sterilization procedures and contraceptives, including emergency contraceptives. Members of the Catholic, evangelical Christian, Mennonite, and Muslim faith communities say that the mandate places them “in the untenable position of having to choose between violating the law and violating their consciences.” [Full Text]

An examination of conscience

Mark J. Kissler

Virtual Mentor. 2013 Mar 1;15(3):185-7. doi:  10.1001/virtualmentor.2013.15.3.fred1-1303. PubMed PMID: 23472804.

“There seems to be no rational way of securing moral agreement in our culture,” mourns Alasdair MacIntyre in the second edition of After Virtue [1]. In place of a common dialogue, we find a fragmented morality made up of individual commitments—commitments whose incommensurability lends, he argues, to the “shrill tone of so much moral debate.” MacIntyre continues, “The rival premises are such that we possess no rational way of weighing the claims of one as against the other.” [Full Text]

Conscience as clinical judgment: medical education and the virtue of prudence

Warren Kinghorn

Virtual Mentor. 2013 Mar 1;15(3):202-5. doi:  10.1001/virtualmentor.2013.15.3.medu1-1303. PubMed PMID: 23472808.

The degree to which “conscience” should guide physician practice has been frequently debated in recent years within medicine, bioethics, and health policy circles [1-3] and has found new life in the debate about various “conscience protection” rules issued by the G. W. Bush and Obama presidential administrations. In these debates, physician “conscience” has been invoked in the medical literature almost exclusively in cases in which physicians attempt to avoid or to decline participation in practices or procedures that they find morally objectionable, often because such practices violate the physician’s religious or cultural practices. In this debate, “conscience” is therefore often associated with religious belief or, at least, with deeply held “values” of the physician in question. [Full Text]

Refusal in “Bartleby, the Scrivener”: Narrative ethics and conscientious objection

Alvan A. Ikoku

Virtual Mentor. March 2013, Volume 15, Number 3: 249-256


In 1853 Herman Melville published “Bartleby, the Scrivener,” his now most well-known piece of short fiction, which over a century and a half later we can certainly read as an illuminating dramatization of conscientious objection [1]. There are, of course, important differences between Melville’s approach to refusal and how we have come to discuss it in medical ethics. The story’s setting, for instance, is not clinical; the central exchanges are between the head of a law office and an employee who politely but insistently refuses to carry out his understood duties. [Full Text]

Conscience, values, and justice in Savulescu

Alvan A. Ikoku

Virtual Mentor. 2013 Mar 1;15(3):208-12. doi: 10.1001/virtualmentor.2013.15.3.jdsc1-1303. PubMed PMID: 23472810


Savulescu’s 2006 article in the British Medical Journal takes up perennially unfinished work on the nature and place of conscience, carried out against the background of contested laws shaped by states and their institutions as well as peoples and their professions. His writing on conscientious objection essentially returns to and intervenes in an extended conversation made possible by continued shifts in relations between individual citizens and loci of authority; shifts that characterized the mid-to-late decades of the twentieth century, when debates about war, civil rights, reproduction, and capital punishment made objection a vital mode of participation and engendered fields of practice and scholarship organized around the mission to decentralize decision making. [Full Text]

Autonomy, conscience, and professional obligation

Robert D. Orr

Virtual Mentor. 2013 Mar 1;15(3):244-8. doi: 10.1001/virtualmentor.2013.15.3.msoc1-1303. PubMed PMID:  23472816.

Health care professionals have a fiduciary relationship with their patients; i.e., because they have greater knowledge and authority than their patients, they have an obligation to be trustworthy and to serve patients’ best interests. This has been taught since the era of Hippocrates and continues in contemporary medicine, as stated, for example, in the American Medical Association’s Principles of Medical Ethics. [Full Text]