Abstract“Conscientious provision” refers to situations in which clinicians wish to provide legal and professionally accepted treatments prohibited within their (usually Catholic) health care institutions. It mirrors “conscientious objection,” which refers to situations in which clinicians refuse to provide legal and professionally accepted treatments offered within their (usually secular) health care institutions. Conscientious provision is not protected by law, but conscientious objection is. In practice, this asymmetry privileges conservative religious or moral values (usually associated with (...) objection) over secular moral values (usually associated with provision). In this article, we first argue for a legal right to one kind of conscientious provision: referral for procedures prohibited at Catholic hospitals. We then argue that a premise in that argument—the principle of comparably trivial institutional burdens—justifies legal protections for some additional forms of conscientious provision that include, for example, writing prescriptions for contraception or medical abortions. However, this principle cannot justify legal protections for other forms of conscientious provision, for instance, the right to perform surgical abortions or gender-affirming hysterectomies at Catholic hospitals. (shrink)

Some physicians in the United States have strong moral objections to the recent bans or near total bans on abortion in this country. The objections are particularly vehement among those who have been abortion providers. They are concerned about the impact of the new restrictions on patients—on their lives and health, especially patients who are socially marginalized and will not be able to travel to “friendly” states to have abortions (i.e., states that legally permit abortions). They are also worried about (...) the status of women, which they fear will be unequal to that of men in a society where women are not permitted to make such intimate decisions about their lives. For these physicians, not to mention their patients, the bans on abortion are morally devastating. They, the physicians, might even feel compelled by their conscience to provide this care—to engage in what some call the “conscientious provision” of care—even though they could lose their careers and their freedom by doing so. There is currently no legal protection for the conscientious provision of abortion care in the U.S., although there is substantial protection for the conscientious refusal of that care. Physicians working in jurisdictions that have abortion bans put themselves at serious legal risk if they defy these bans for reasons of conscience. In general, their freedom of conscience is very low compared to that of physicians who conscientiously refuse to provide abortions in jurisdictions where abortions are still legal. Using theories of conscience and conscientious objection that I develop in Conscience in Reproductive Health Care (Oxford 2020), I argue that this situation is morally untenable. (shrink)

Some authors argue that it is permissible for clinicians to conscientiously provide abortion services because clinicians are already allowed to conscientiously refuse to provide certain services. Call this the symmetry thesis. We argue that on either of the two main understandings of the aim of the medical profession—what we will call “pathocentric” and “interest‐centric” views—conscientious refusal and conscientious provision are mutually exclusive. On pathocentric views, refusing to provide a service that takes away from a patient's health is (...) professionally justified because there are compelling reasons, based on professional standards, to refuse to provide that service (e.g., it does not heal, and it is contrary to the goals of medicine). However, providing that same service is not professionally justified when providing that service would be contrary to the goals of medicine. Likewise, the thesis turns out false on interest‐centric views. Refusing to provide a service is not professionally justified when that service helps the patient fulfill her autonomous preferences because there are compelling reasons, based on professional standards, to provide that service (e.g., it helps her achieve her autonomous preferences, and it would be contrary to the goals of medicine to deny her that service). However, refusing to provide that same service is not professionally justified when refusing to provide that service would be contrary to the goals of medicine. As a result, on either of the two most plausible views on the goals of medicine, the symmetry thesis turns out false. (shrink)

Conscientious refusal involves decisions by healthcare workers, on grounds of their conscience, to refuse to provide legal, professionally permissible and safe health interventions to patients. Conscientious provision involves decisions by healthcare workers, also on grounds of conscience, to provide safe and beneficial healthcare to patients that is prohibited by law or policy. Some bioethicists believe that the moral issues governing both are identical, and that if one permits conscientious refusals, one should also permit conscientious provisions. (...) This article argues that this assumption of symmetry is incorrect. To demonstrate this, it does the following: first, it establishes why it matters that we understand the difference between them; second, it describes three recent cases of conscientious provision in Canadian healthcare to help characterize its nature and scope; third, it situates these cases in a socio-economically nuanced analysis of the role of the conscientious provider under conditions or privilege and oppression; finally, it applies insights from the cases and the intersectional analysis to common criticisms of conscientious refusal to reinforce the fundamental asymmetries between conscientious refusal and conscientious provision. (shrink)

Should doctors ever be allowed to offer care that their state or employer forbids? What if their deeply held personal values or beliefs demand they treat patients in need? We’re used to hearing abo...

The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court's decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare (...) providers on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women's rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience. (shrink)

While many Catholic hospitals permit the prescription of the emergency contraception drug levonorgestrel for rape victims, some continue to prohibit this practice as a matter of institutional conscience. While the standard approach to this issue has been to offer an argument that levonorgestrel either is or is not morally permissible, we have taken a different tack. We begin by briefly describing and acknowledging that reasonable disagreement exists on this question (part one), and then arguing that the reasonable disagreement itself can (...) serve as a compelling basis for Catholic leadership at hospitals that prohibit emergency contraception for rape victims to accommodate physicians who wish to provide levonorgestrel as a matter of conscience (part two). We end by anticipating and responding to some objections. (shrink)

We argue that, in certain circumstances, doctors might beprofessionallyjustified to provide abortions even in those jurisdictions where abortion is illegal. That it is at least professionally permissible does not mean that they have an all-things-considered ethical justification or obligation to provide illegal abortions or that professional obligations or professional permissibility trump legal obligations. It rather means that professional organisations should respect and indeed protect doctors’ positive claims of conscience to provide abortions if they plausibly track what is in the best (...) medical interests of their patients. It is the responsibility of state authorities to enforce the law, but it is the responsibility of professional organisations to uphold the highest standards of medical ethics, even when they conflict with the law. Whatever the legal sanctions in place, healthcare professionals should not be sanctioned by the professional bodies for providing abortions according to professional standards, even if illegally. Indeed, professional organisation should lobby to offer protection to such professionals. Our arguments have practical implications for what healthcare professionals and healthcare professional organisations may or should do in those jurisdictions that legally prohibit abortion, such as some US States after the reversal ofRoe v Wade. (shrink)

What is conscientious objection? -- Should conscientious objectors be accommodated? -- Assessing objectors' beliefs and reasons -- Accommodation and conscientious provision.

Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any (...) action contrary to their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care. (shrink)

Background: Ethical nursing practice is increasingly challenging, and strategies for addressing ethical dilemmas are needed to support nurses’ ethical care provision. Conscientious objection is one such strategy for addressing nurses’ personal, ethical conflicts, at times associated with conscience. Exploring both conscience and conscientious objection provides understanding regarding their implications for ethical nursing practice, research, and education. Research aim: To analyze the concepts of conscience and conscientious objection in the context of nurses. Design: Concept analysis using the (...) method by Walker and Avant. Research context: Data were retrieved from Philosopher’s Index, PubMed, and CINAHL with no date restrictions. Ethical consideration: This analysis was carried out per established, scientific guidelines. Findings: Ethical concepts are integral to nursing ethics, yet little is known about conscientious objection in relation to conscience for nurses. Of note, both concepts are well established in ethics literature, addressed in various nursing codes of ethics and regulatory bodies, but the meaning they hold for nurses and the impact they have on nursing education and practice remain unclear. Discussion and conclusion: This article discusses the relevance of conscience and conscientious objection to ethical nursing practice and proposes a model case to show how they can be appreciated in the context of nurses. Conscientious objection is an option for ethical transparency for nurses but is situated in contentious discussions over its use and has yet to be fully understood for nursing practice. Conscience is an element in need of more exploration in the context of conscientious objection. Further research is warranted to understand how nurses respond to conscience concerns in morally, pluralistic nursing contexts. (shrink)

In this paper, I argue that the conscience clause around abortion provision in England, Scotland and Wales is inadequate for two reasons. First, the patient and doctor are differently situated with respect to social power. Doctors occupy a position of significant moral and epistemic authority with respect to their patients, who are vulnerable and relatively disempowered. Doctors are rightly required to disclose their conscientious objection, but given the positioning of the patient and doctor, the act of doing so (...) exploits the authority of the medical establishment in asserting the legitimacy of a particular moral view. Second, the conscientious objector plays an unusual and self-defeating moral role. Since she must immediately refer the patient on to another doctor who does not hold a conscientious objection, she becomes complicit, via her necessary causal role, in the implementation of the procedure. This means that doctors are not able to prevent abortions, rather, they are required to ensure that they... (shrink)

Conscientious objection was barely mentioned in debates about the ethics of healthcare provision before the 1970s.1 The conscientious objections that attracted public and academic attention were those of conscripts who objected to participation in military forces, and of parents who objected to the vaccination of their children. All of this was changed by the 1973 US Supreme Court decision Roe v. Wade, which established a constitutional right to abortion in the USA. Shortly after this decision, the American (...) Medical Association's (AMA) House of Delegates, the peak policy-making body within the AMA, adopted a resolution that sought to protect hospital employees from having to contribute to the provision of abortion if they felt that doing so was immoral. The resolution was adopted in response to a specific controversial court decision, but the language employed in it was broad in scope. House of Delegates Health Policy 5.995 contained a conscience clause stating that ‘Neither physician, hospital, …. (shrink)

Recently, debate over whether health care providers should have a protected right to conscientiously refuse to offer legal health care services—such as abortion, elective sterilization, aid in dying, or treatments for transgender patients—has grown exponentially. I advance a modified compromise view that bases respect for claims of conscientious refusal to provide specific health care services on a publicly defensible rationale. This view requires health care providers who refuse such services to disclose their availability by other providers, as well as (...) to arrange for referrals or facilitate transfers of care. This requirement raises the question of whether providers are being forced to be complicit in the provision of services they deem to be morally objectionable. I conclude by showing how this modified compromise view answers the most significant objections mounted by critics of the right to conscientious refusal and safeguards providers from having to offer services that most directly threaten their moral integrity. (shrink)

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious (...) objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise—a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected. (shrink)

Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion. We conducted a systematic (...) review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection. Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons. The reasons and their associated mentions in this category outnumber those in the sum of the other three categories. We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals. (shrink)

“It's almost like putting salt in a wound, for this person who's already made a very difficult decision,” suggested Meghan Patterson, a licensed obstetrician-gynecologist whom we interviewed in our qualitative study of the experiences of North Carolina abortion providers practicing under the state's Woman's Right to Know Act. The act requires that women receive counseling with state-mandated information at least twenty-four hours prior to obtaining an abortion. After the law was passed, Patterson worked with clinic administrators, in consultation with a (...) lawyer, to write a script to be used in the state-mandated counseling procedure. She and her colleagues took particular steps to mitigate the effects of what she described as HB 854's “forced language”—such as referring to the “father of the child.” While HB 854 stipulated that patients must be informed of the medical risks associated with the particular abortion procedure as well as those of carrying the child to term, Patterson's script made explicit the magnitude of comparative risks, emphasizing that the risks of carrying a pregnancy to term are substantially greater than the risks of an early-term abortion. She felt that these contextualization strategies helped to facilitate trust and rapport in a clinical care situation that proved relationally and morally challenging. In this article, we take up and expand on this point by elucidating an empirically grounded approach to ethically justified care when health care providers face legal or institutional policy mandates that raise possible moral conflicts. Our approach builds on recent bioethics discourse addressing conscience in the practice of medicine. While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious objection or refusal. Here, we suggest a broader frame for thinking about claims of conscience in health care. Our approach draws on the feminist bioethics and the ethics of care literatures to highlight how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. What emerges are two possibilities: not only conscientious refusal to comply with a policy mandate but also conscientious compliance—working conscientiously within a mandate's confines. (shrink)

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion (...) provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice. (shrink)

Background While most countries that allow abortion on women’s request also grant physicians a right to conscientious objection (CO), this has proven to constitute a potential barrier to abortion access. Conscientious objection is regarded as an understudied phenomenon the effects of which have not yet been examined in Germany. Based on expert interviews, this study aims to exemplarily reconstruct the processes of abortion in a mid-sized city in Germany, and to identify potential effects of conscientious objection. Methods (...) Five semi-structured interviews with experts from all instances involved have been conducted in April 2020. The experts gave an insight into the medical care structures with regard to abortion procedures, the application and manifestations of conscientious objection in medical practice, and its impact on the care of pregnant women. A content analysis of the transcribed interviews was performed. Results Both the procedural processes and the effects of conscientious objection are reported to differ significantly between early abortions performed before the 12th week of pregnancy and late abortions performed at the second and third trimester. Conscientious objection shows structural consequences as it is experienced to further reduce the number of possible providers, especially for early abortions. On the individual level of the doctor-patient relationship, the experts confirmed the neutrality and patient-orientation of the vast majority of doctors. Still, it is especially late abortions that seem to be vulnerable to barriers imposed by conscientious objection in individual medical encounters. Conclusion Our findings indicate that conscientious objection possibly imposes barriers to both early and late abortion provision and especially in the last procedural steps, which from an ethical point of view is especially problematic. To oblige hospitals to partake in abortion provision in Germany has the potential to prevent negative impacts of conscientious objection on women’s rights on an individual as well as on a structural level. (shrink)

The Swedish solution to the legal handling of professional conscientious refusal in healthcare is described. No legal right to conscientious refusal for any profession or class of professional tasks exists in Sweden, regardless of the religious or moral background of the objection. The background of this can be found in strong convictions about the importance of public service provision and related civic duties, and ideals about rule of law, equality and non-discrimination. Employee's requests to change work tasks (...) are handled on a case-by-case basis within the frames of labour law, ensuring full voluntariness, and also employer's privilege regarding the organisation and direction of work, and duties of public institutions to provide services. Two complicating aspects of this solution related to the inclusion of ‘alternative medical’ service providers in a national health service, and professional insistence on conscientious refusal rights to accept legalised assisted dying are discussed. The latter is found to undermine the pragmatic reasons behind recent attempts by prolife groups to challenge the Swedish solution related to legal abortion in courts. (shrink)

Although one can argue that they do not represent a radical departure from existing practices, protocols for reverse triage certainly step beyond what is ordinarily done in medicine and healthcare. Nevertheless, there seems to be some degree of moral concern regarding the ethical legitimacy of practicing reverse triage in the context of a pandemic. Such concern can be taken as a reflection of the moral antipathy some exhibit towards current practices of withdrawing treatment—that is, when withdrawal of treatment is arguably (...) in the best interests of patients—and a rejection of the purported normative insignificance of withholding and withdrawing. Given that the relevance of the psychological attitudes of some healthcare professionals to the moral assessment of withdrawing and withholding treatment continues to be debated, it would seem that some thought should be given to the introduction and implementation of reverse triage decisions in response to a pandemic. This brief paper will consider if provision should be made for healthcare professionals to conscientiously refuse to participate in reverse triage. (shrink)

ABSTRACTSince 2007, when Mexico City decriminalized abortion during the first trimester, a debate has been taking place regarding abortion and the right to conscientious objection. Many people argue that, since the provision of abortions is now a statutory duty of healthcare personnel there can be no place for “conscientious objection.” Others claim that, even if such an objection were to be allowed, it should not be seen as a right, since talk about a right to CO may (...) lead to a slippery slope where we may end up recognizing a right to disobey the law. In this paper, I argue that there is a right to CO and that this may be justified through the notions of autonomy and integrity, which a liberal democracy should respect. However, it cannot be an absolute right, and in the case of abortion, it conflicts with women’s reproductive rights. Therefore, CO should be carefully regulated so that it does not obstruct the exercise o... (shrink)

BackgroundIn 2019, the Constitutional Court of South Korea ruled that the anti-abortion provisions in the Criminal Act, which criminalize abortion, do not conform to the Constitution. This decision will lead to a total reversal of doctors’ legal duty from the obligation to refuse abortion services to their requirement to provide them, given the Medical Service Act that states that a doctor may not refuse a request for treatment or assistance in childbirth. I argue, confined to abortion services in Korea that (...) will take place in the near future, that doctors should be granted the legal right to exercise conscientious objection to abortion.Main textConsidering that doctors in Korea have been ethically and legally obligated to refrain from abortions for many years, imposing a universal legal duty to provide abortions that does not allow exception may endanger the moral integrity of individual doctors who chose a career when abortion was illegal. The universal imposition of such a duty may result in repudiation of doctors as moral agents and damage trust in doctors that forms the basis of medical professionalism. Even if conscientious objection to abortion is granted as a legal right, most patients would experience no impediment to receiving abortion services because the healthcare environment of Korea provides options in which patients can choose their doctors based on prior information, there are many doctors who would be willing to provide an abortion, and Korea is a relatively small country. Finally, the responsibility to effectively balance and guarantee the respective rights of the two agents involved in abortion, the doctor and the patient, should be imposed on the government rather than individual doctors. This assertion is based on the government’s past behaviours, the nature of its relationship with doctors, and the capacity it has to satisfy both doctors’ right to conscientious objection and patients’ right to legal medical services.ConclusionWith regard to abortion services that will be sought in the near future, doctors should be granted the legal right to exercise conscientious objection based on the importance of doctor’s moral integrity, lack of impediment to patients, and government responsibility. (shrink)

Some contributions to the current literature on conscience objection in healthcare posit the notion that the requirement to refer patients to a non-objecting provider is a morally questionable undertaking in need of explanation. The issue is that providing a referral renders those who conscientiously object to being involved in a particular intervention complicit in its provision. This essay seeks to engage with such claims and argues that referrals can be construed in terms of what Harman calls morally permissible moral (...) mistakes. I go on to suggest that one might frame the (in)actions of those who exercise the right of non-participation generated by the claim to conscientiously object in similar terms; they can also be considered morally permissible moral mistakes. Finally, and given that the arguments already advanced involve simultaneously looking at the same issue from competing ethical perspectives, I offer some brief remarks that support viewing conscientious objection as an ethicopolitical device. (shrink)

In Ethiopia, conscientious objection (CO) to abortion provision is not allowed due to government regulations. We here report findings from a qualitative interview study of 30 healthcare professionals from different professions working with abortion in Addis Ababa, Ethiopia. CO is practised despite the regulations forbidding it. Most informants appeared to be unfamiliar with the prohibition or else did not accord it weight in their moral reasoning. Proponents of institutionalization/toleration of CO claimed that accommodation was often feasible in a (...) hospital setting because colleagues could take over. Opponents pointed to threats to patient access in rural settings especially. Both proponents and opponents invoked tenets of professional ethics, viz., the right not to be coerced into actions one deems unacceptable, or the duty to provide care, respectively. More societal and professional discussion of the ethics and regulation of CO, and a clearer link between legal regulation and ethical guidance for professionals, are called for. (shrink)

In jurisdictions where voluntary assisted dying is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While (...) this protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture. There are no data in this work. (shrink)

Despite significant progress in the legalization and decriminalization of abortion in Australia over the past decade or more recent research and government reports have made it clear that problems with the provision of services remain. This essay examines such issues and sets forth the view that such issues can and should be seen as (bio)ethical concerns. Whilst conscientious objection—the right to opt-out of provision on the basis of clear ethical reservations—is a legally and morally permissible stance that (...) healthcare professionals can adopt, this does not mean those working in healthcare can simply elect not to be providers absent a clear ethical rationale. Furthermore, simple non-provision would seem to contravene the basic tenants of medical professionalism as well as the oft raised claims of the healthcare professions to put the needs of patients first. Recognizing that much of the progress that has been made over the past three decades can be attributed to the efforts of dedicated healthcare professionals who have dedicated their careers to meeting the profession’s collective responsibilities in this area of women’s health and reproductive healthcare, this paper frames the matter as a collective ethical lapse on the part of healthcare professionals, the healthcare professions and those involved in the management of healthcare institutions. Whilst also acknowledging that a range of complex factors have led to the present situation, that a variety of steps need to be taken to ensure the proper delivery of services that are comprehensive, and that there has been an absence of critical commentary and analysis of this topic by bioethicists, I conclude that there is a need to (re)assess the provision of abortion in Australia at all levels of service delivery and for the healthcare professions and healthcare professionals to take lead in doing so. That this ought to be done is clearly implied by the healthcare profession’s longstanding commitment to prioritizing the needs of patient over their own interests. (shrink)

We describe a number of conscientious objection cases in a liberal Western democracy. These cases strongly suggest that the typical conscientious objector does not object to unreasonable, controversial professional services—involving torture, for instance—but to the provision of professional services that are both uncontroversially legal and that patients are entitled to receive. We analyse the conflict between these patients' access rights and the conscientious objection accommodation demanded by monopoly providers of such healthcare services. It is implausible that (...) professionals who voluntarily join a profession should be endowed with a legal claim not to provide services that are within the scope of the profession's practice and that society expects them to provide. We discuss common counterarguments to this view and reject all of them. (shrink)

The 2012 contraception mandate issued by the US Department of Health and Human Services has intensified the debate over a health care practitioner’s right to conscientiously object to providing contraception. This paper approaches the debate over conscientious objection to contraception from a pharmacist’s standpoint. It shows that contraception is the cause of or a contributing factor to observed psychosocial suffering and is not “preventive health care” as labeled. It argues not only that a pharmacist should have the right to (...) conscientiously object to dispensing contraception but also that, given the mission of the pharmacist as a health care practitioner, a pharmacist is obligated to refuse to dispense contraception. The paper argues that the obligation to refuse to dispense contraception applies to all who are involved in the provision of health care. National Catholic Bioethics Quarterly 12.4 (Winter 2012): 675–696. (shrink)

The dispute over professional conscientious objection presumes a picture of medicine as a practice governed by rules. This rule-based conception of medical practice is identifiable with John Rawls’s conception of social practices. This conception does not capture the character of medical practice as experienced by practitioners, for whom it is a sensibility or “form of life” rather than rules. Moreover, the sensibility of medical practice as experienced by physicians is at best neutral, and at worst hostile, to the demands (...) of those who would override physician conscientious objection to the provision of currently contested services. That being so, calls for overriding physician conscientious objection are much more demanding of the medical profession than they appear in light of Rawls’s view. As such overriding may entail the forcible transformation of medicine’s form of life, the author contends that it would be more prudent to provide contested services by circumventing the medical profession than by compelling it. (shrink)

In December 2017, Law 219/2017, ‘Provisions for informed consent and advance directives’, was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues are addressed in the law. What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment – concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law maximizes (...) the value of the patient’s time to decide. Every patient is allowed to make choices for the present as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives. The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual’s resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field. (shrink)

In _Leviathan Hobbes offers an argument for the conclusion that one is bound to obey one's sovereign even when one judges that obedience to the sovereign's command would require one to disobey a law of God. The basis for Hobbes's argument is his contention that the covenant that institutes sovereignty includes the renunciation of the right to act in accordance with one's private conscience. In this paper I show that Hobbes's argument fails because one that takes the law of the (...) sovereign to be contrary to the law of God should, by Hobbes's lights, see the provision of the covenant requiring renunciation of conscience as void. (shrink)

In the article “Principled Conscientious Provision: Referral Symmetry and Its Implications for Protecting Secular Conscience,” Abram L. Brummett, Tanner Hafen, and Mark C. Navin reject what they call the “referral asymmetry” in U.S. conscientious objection law in medicine, which recognizes rights of conscientiously objecting physicians to withhold referrals for medical interventions but does not (yet) recognize rights of physicians to make referrals for medical interventions to which they are morally committed but to which their health care institutions (...) are morally opposed. This commentary concentrates on a second asymmetry, namely, the relationship of a health care provider's referral or nonreferral to the medical standard of care. The commentary argues that this second asymmetry seems to require action more appropriately recognized as civil disobedience than conscientious provision of referral. (shrink)

Kyle Fritz argues for the following conditional statement: if healthcare providers should be allowed to conscientiously object to providing abortions in jurisdictions where abortions...

The debate about positive and negative claims of conscience is, in large part, about ethical consistency. In this commentary I argue that there can be differences between conscientious provision of treatment and conscientious nonprovision of treatment that are ethically relevant. However, in many cases, including those described in this commentary, there is not sufficient ethical reason to treat them differently. This means that asymmetrical conscientious objection policies are potentially unjustified.

Giubiliniet aloffer some helpful reflections on the conscientious provision of medical care and whether and in what circumstances professional associations ought to support the conscientious provision of abortion in circumstances where abortion is banned or heavily restricted. I have several reservations, however, about the argument developed in the article. First, the essay makes questionable use of the case of Savita Halappanavar to justify its central argument about conscientious provision. Second, there is an apparent inconsistency (...) between this article and the authors’ statements elsewhere about the conscientious refusal of care. Third, there are risks that attend to professional associations supporting practitioners who break the law, and yet Giubiliniet aldo not give sufficient attention to this. This response will briefly discuss these three concerns. (shrink)

Catholic health care is often viewed as antithetical to secular conceptions of autonomy. This view can engender calls to protect “choice” in Catholic facilities. However, this view is built on a fundamental misunderstanding of the Ethical and Religious Directives for Catholic Health Care Services (ERDs). This commentary, which responds to “Principled Conscientious Provision: Referral Symmetry and Its Implications for Protecting Secular Conscience,” by Abram Brummett et al., seeks to demonstrate the nuance of the ERDs as well as to (...) address some of the challenges various Catholic identities have when interpreting and living out the ERDs so that all patients receive high-quality, compassionate care. By highlighting the Church's desire to protect all people at every stage, I hope to dispel the caricatures that often result from misunderstandings by Catholics and non-Catholics alike. (shrink)

While there is a prolific debate surrounding the issue of conscientious objection of individuals towards performing certain clinical acts, this debate ignores the fact that there are other reasons why clinicians might wish to object providing specific services. This paper briefly discusses the idea that healthcare workers might object to providing specific services because they are against their professional judgement, they want to maintain a specific reputation, or they have pragmatic reasons. Reputation here is not simply understood as being (...) in good standing with a professional body. Rather, reputation is treated in the sense that a craftsman might wish to be known for providing a specific type, quality, and style of service. Professionalism is understood as acting according to the philosophical and scientific principles that are the basis of healthcare (such as acting for the benefit of the patient’s health and following well- evidenced treatment pathways). (shrink)

It is a widely supported claim that liberal democratic institutions should treat citizens with equal respect. I neither dispute nor champion this claim, but investigate how it could be fulfilled. I do this by asking, as a sort of litmus test, how liberal democratic institutions should treat with respect citizens holding minority convictions, and thereby dissenting from a deliberative output. The first step of my argument consists in clarifying the sense in which liberal democracies have a primary concern for the (...) respectful treatment of citizens qua self-legislating persons. Taking the second step, I address critically the common tendency in the literature to concentrate on what I have termed the ex ante legem phase, focusing solely on the structure of institutionalized decision-making processes. I submit, rather, that the principle of equal respect for persons demands more of liberal democratic institutions to enhance citizens' chances to give voice to their consciences and influence, on that ground, the formulation of the rules to which they should conform. Fulfilling this commitment requires democratic theorizing to go beyond the ex ante legem phase and regard forms of ex post legem contestation as an extension of citizens' right to political participation. Against this backdrop, I take the third and last step and argue that a promising way forward consists in the adoption of an ex post legem version of conscientious exemptionism, granting citizens a conditional moral right to request exemptions on the grounds of conscience from certain controversial legal and political provisions. (shrink)

In England and Wales, there is significant controversy on the law related to abortion. Recent discussions have focussed predominantly on the health professional's right to conscientious objection. This article argues for a comprehensive overhaul of the law from the perspective of an author who adopts the view that all unborn human beings should be granted the prima facie right to life. It is argued that, should the law be modified in accordance with this stance, it need not imply that (...) health professionals should enjoy an unqualified right to object to participating in the provision of abortion. Indeed, it is proposed that – in some situations – women should be granted a positive right to abortion. While the focus of this article is on changing the law in England and Wales, it is hoped that the position developed here will also inspire legal debate and reform elsewhere. (shrink)

Introduction : philanthropy in democratic societies / Rob Reich, Lucy Bernholz, and Chiara Cordelli -- Altruism and the origins of nonprofit philanthropy / Jonathan Levy -- Why is the history of philanthropy not a part of American history? / Olivier Zunz -- On the role of foundations in democracies / Rob Reich -- Contributory or disruptive : do new forms of philanthropy erode democracy? / Aaron Horvath and Walter W. Powell -- Reconciling corporate social responsibility and profitability : guidelines for (...) the conscientious manager / Paul Brest -- When is philanthropy? : how the tax code's answer to this question has given rise to the growth of donor-advised funds and why it's a problem / Ray D. Madoff -- Creating digital civil society : the Digital Public Library of America / Lucy Bernholz -- The free-provider problem : private provision of public responsibilities / Eric Beerbohm -- Philanthropy and democratic ideals / Ryan Pevnick -- Reparative justice and the moral limits of discretionary philanthropy / Chiara Cordelli. (shrink)

In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors' personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. (...) We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: removing a right to conscientious objection; selecting candidates into relevant medical specialities or general practice who do not have objections; demonopolizing the provision of these services away from the medical profession. (shrink)

Does the morality of abortion depend on the moral status of the human fetus? Must the law of abortion presume an answer to the question of when personhood begins? Can a law which permits late abortion but not infanticide be morally justified? These are just some of the questions this book sets out to address. With an extended analysis of the moral and legal status of abortion, Kate Greasley offers an alternative account to the reputable arguments of Ronald Dworkin and (...) Judith Jarvis Thomson and instead brings the philosophical notion of 'personhood' to the foreground of this debate. Structured in three parts, the book will consider the relevance of prenatal personhood for the moral and legal evaluation of abortion; trace the key features of the conventional debate about when personhood begins and explore the most prominent issues in abortion ethics literature: the human equality problem and the difference between abortion and infanticide; and examine abortion law and regulation as well as the differing attitudes to selective abortion. The book concludes with a snapshot into the current controversy surrounding the scope of the right to conscientiously object to participation in abortion provision. (shrink)

Conscience-based refusals by health care professionals to provide care to eligible patients are problematic, given the monopoly such professionals hold on the provision of such services. This article reviews standard ethical arguments in support of conscientious refuser accommodation and finds them wanting. It discusses proposed compromise solutions involving efforts aimed at testing the genuineness and reasonability of refusals and rejects those solutions too. A number of jurisdictions have introduced policies requiring conscientious refusers to provide effective referrals. These (...) policies have turned out to be unworkable. They subject patients to a health care delivery lottery, which is incompatible with the fundamental values of medical professionalism. This paper sheds light on transnational efforts aimed at undermining progress made in reproductive health by means of conscientious refusal accommodation claims. The view that the accommodation of conscientious refusers is indefensible on consequentialist ethical grounds, as well as on grounds related to medical professionalism itself, is defended. (shrink)

The concept of family economy in Islam has been addressed under various issues in classical sources though not extensively discussed in the classical literature. Islamic jurisprudence generally embraces pragmatical approach and pays attention to the needs of society. It is evident that economic relationship within the family is not addressed under a single heading in classical sources, but rather evaluated under numerous headings. From this perspective, it can be observed that each individual within the family concept enjoys distinct economic rights (...) and responsibilities. The social, ethical and financial responsibilities in the family are carried out within the framework of maintenance. In this respect, the Islamic legal system approaches the concept of family economy with a balanced view between income and expenditure, lawful and unlawful, and blessing and burden, and does not evaluate the issue purely as an economic activity. However, in contemporary times, the term family economy is understood more in terms of the economic and legal statues of the individuals within the family, such as their handling and responsibilities concerning acquired properties and the nature and manner of property distribution. This approach significantly diverges from the individual and social responsibilities entailed by property ownership in Islamic law. In Islam, the possession of individual economic rights and freedoms does not imply that one has no responsibilities towards others and cannot act irresponsibly. Based on this fundamental paradigm difference, this article aims to analyze the concept of family economy from the standpoint of Islamic law, discussing what it is and is not. The study has revealed that, even today, economic interests and activities within the family sometimes lead to conflicts, causing the parties to abandon their ethical and religious responsibilities in favor of establishing definite lines solely based on legal grounds. This, in turn, significantly undermines the essence and continuity of being and remaining a family. Furthermore, when examining writings that attempt to explain the economic status of the family according to Islamic law, it is evident that the provisions found in classical fiqh books, which were arranged according to the human, Islamic, and customary structure of that period and were quite functional, are repeated without considering the contemporary societal structure and changing human character. Although these provisions are accurate and effective within their own context, they are deemed inapplicable by modern individuals, rendering them ineffective. The appropriate way to address this issue can be to emphasize that the rules concerning family economy in classical fiqh are not merely ethical and conscientious, but that legal intervention will ensue if they are not adhered to. The fundamental assertion of this article is based on this premise: the concept of family economy inherently exists in Islamic law, imposes various responsibilities on the parties, is structured on a balance of blessings and burdens, and entails legal, ethical and religious responsibilities. (shrink)

Background: The development of a profession’s autonomy closely relates to that profession’s level of autonomy in performing its specific role. For the nursing profession, this key role is nursing care. Objectives: This study was undertaken to evaluate the professional autonomy of nurses in care provision, from an ethical perspective. Research design: A mixed methods approach is employed in this research, which makes use of both quantitative and qualitative methods. The quantitative dimension of this research covers sociodemographic aspects and makes (...) use of the Sociotropy–Autonomy Scale. The qualitative dimension of the research relates to the factors that affect professional autonomy in nursing care. Participants and research context: The sample consisted of 30 nurses working in the orthopedics, neurology, or intensive care units of three hospitals. Ethical considerations: Before conducting this research, we received permission from the ethical committee, as well as written permits from all the institutions in which the research was carried out. Informed consent was obtained from all participants. Findings: According to the findings of this study, only 6.7% of the nurses surveyed stated that nurses had professional autonomy; they also stated that professional autonomy in nursing was mostly restricted by the need to be “dependent upon the physician in nursing implementations” and that autonomy in nursing care was mostly limited by a “high number of patients per nurse.” Discussion: This study determined that delays in resolving problems with regard to professional autonomy in nursing care in Turkey could be creating many of the professional and ethical problems that nurses face there. Conclusion: It is recommended that: individuals choose the nursing profession conscientiously; nurses need to be given professional awareness; their professional organizations need to be strengthened; and plans need to be made to increase research and to accumulate both knowledge and expertise. (shrink)

For many liberal democrats toleration has become a sort of pet-concept, to which appeal is made in the face of a myriad issues related to the treatment of minorities. Against the inflationary use of toleration, whether understood positively as recognition or negatively as forbearance, I argue that toleration may not provide the conceptual and normative tools to understand and address the claims for accommodation raised by at least one kind of significant minority: democratic dissenting minorities. These are individuals, or aggregates (...) of them, who oppose, on principled grounds, the outcomes of the majoritarian decision-making process. I argue that democratic dissenting minorities' claims are better understood as calls for respect for a person's capacity for self-legislation. I view respect as the cornerstone of justice in a liberal democracy: all norms resulting in a constraint on a person's conduct should be appropriately justified to her. I argue that the reconciliation of democratic dissenting minorities' claims requires an enhancement of the justificatory strategies of democratic decisions by enhancing in turn citizens' rights to political participation. This should be done both during decision making and after a provision is enacted by also securing space for contestation through such forms of illegal protest as civil disobedience and conscientious objection. (shrink)

Background: The development of a profession’s autonomy closely relates to that profession’s level of autonomy in performing its specific role. For the nursing profession, this key role is nursing care. Objectives: This study was undertaken to evaluate the professional autonomy of nurses in care provision, from an ethical perspective. Research design: A mixed methods approach is employed in this research, which makes use of both quantitative and qualitative methods. The quantitative dimension of this research covers sociodemographic aspects and makes (...) use of the Sociotropy–Autonomy Scale. The qualitative dimension of the research relates to the factors that affect professional autonomy in nursing care. Participants and research context: The sample consisted of 30 nurses working in the orthopedics, neurology, or intensive care units of three hospitals. Ethical considerations: Before conducting this research, we received permission from the ethical committee, as well as written permits from all the institutions in which the research was carried out. Informed consent was obtained from all participants. Findings: According to the findings of this study, only 6.7% of the nurses surveyed stated that nurses had professional autonomy; they also stated that professional autonomy in nursing was mostly restricted by the need to be “dependent upon the physician in nursing implementations” and that autonomy in nursing care was mostly limited by a “high number of patients per nurse.” Discussion: This study determined that delays in resolving problems with regard to professional autonomy in nursing care in Turkey could be creating many of the professional and ethical problems that nurses face there. Conclusion: It is recommended that: individuals choose the nursing profession conscientiously; nurses need to be given professional awareness; their professional organizations need to be strengthened; and plans need to be made to increase research and to accumulate both knowledge and expertise. (shrink)

Throughout the 3-year war in Lebanon (1982-1985) and throughout the 7 years of the first Intifada (1987-1994), about 170 objecting reservists chose to adopt an unconventional mode of moral resolution for their dilemma about service in the conflict: they disobeyed the order to serve in the war zone when their unit was called up. They argued that such service would contradict the dictates of their conscience. At the outset, the intention of most of these reservists was to comply with orders (...) for general military service. They asked to serve within the Green Line. When their request was overruled and they continued to disregard their call-up, they were charged with a disciplinary offense (Israel has no legal provision for selective conscientious objection). They subsequently were tried by court-martial and were sentenced to 14-35 days in military prison, some of them more than once when they refused additional drafts. Their major conscientious claims revolve around two major constraints: resisting the unfair physical load of military reserve service and resisting the obligation to face morally no-win situations. I would further argue that even though most of the public and the senior army echelons were familiar with these two types of moral voices, they preferred to remove the conscientious soldiers from their posts, or to ignore the claims themselves. (shrink)

The American Medical Association’s (AMA’s) “Opinion 1.1.7, Physician Exercise of Conscience” attempts to help physicians strike a reasonable balance between their own conscientious beliefs and their patients’ medical interests in an effort to minimize harms to both. However, some ambiguity still remains as to whether the severity of harms experienced by physicians and patients is to be assessed externally (by policy makers or by a professional body like the AMA), or internally by the subjects of those harms. Conflicts between (...) conscientious physicians’ self-assessments of the moral harm associated with various actions and the AMA’s external assessments of such harms are likely to lead to challenges in the implementation of some provisions of its opinion. This commentary argues, however, that provisions (b) and (e) of the opinion, which describe the information physicians should provide about their own scope of practice and about the existence of controversial procedures, are less likely to conflict with physicians’ subjective assessments of moral harm, and therefore will face fewer challenges in implementation. (shrink)