Guidelines for conscientious objection in Spain: a proposal involving prerequisites and protocolized procedure.

Healthcare professionals often face ethical conflicts and challenges related to decision-making that have necessitated consideration of the use of conscientious objection (CO). No current guidelines exist within Spain's healthcare system regarding acceptable rationales for CO, the appropriate application of CO, or practical means to support healthcare professionals who wish to become conscientious objectors. As such, a procedural framework is needed that not only assures the appropriate use of CO by healthcare professionals but also demonstrates its ethical validity, legislative compliance through protection of moral freedoms and patients' rights to receive health care. Our proposal consists of prerequisites of eligibility for CO (individual reference, specific clinical context, ethical justification, assurance of non-discrimination, professional consistency, attitude of mutual respect, assurance of patient rights and safety) and a procedural process (notification and preparation, documentation and confidentiality, evaluation of prerequisites, non-abandonment, transparency, allowance for unforeseen objection, compensatory responsibilities, access to guidance and/or consultative advice, and organizational guarantee of professional substitution). We illustrate the real-world utility of the proposed framework through a case discussion in which our guidelines are applied.

Conscientious refusal or conscientious provision: We can't have both.

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.

Conscience and Vaccines: Lessons from Babylon 5 and COVID-19.

Babylon 5, like other great sci-fi franchises, touched on important ethical questions. Two ethical conundrums relating to the series' main characters included providing life-saving treatment to a child against their parents' wishes and potential involvement with a highly beneficial but morally dubious medication. I use these cases to discuss some aspects of the COVID-19 vaccines' development and roll-out, demonstrating that people (be it patients or clinicians) might object to some vaccines due to reasonable ethics and safety-based concerns rather than due to an anti-vaxxer mind-set. I highlight that it would be disingenuous to lump these two groups of objections together for not all objections to specific vaccines are objections to vaccination in general. Rather, governments and pharmaceutical companies should seriously engage with the concerns of reasonable objectors to provide citizens with the appropriate products and ensure large vaccination uptake - in the case of COVID-19 this should include giving patients the choice of the product they will be inoculated with.

Physician autonomy or discrimination: the risks and limits of saying "no".

Respect for patient autonomy is a critical concept in the training of all physicians. Most physicians will make clinical recommendations on a daily basis that reflect a marriage of evidence-based medical fact and the deeply felt aspirations and boundaries that patients share with them. While most physicians are well versed and comfortable managing issues of patient autonomy, many are less confident about ethical and legal guidelines for expressing their own autonomy in clinical decision-making. This paper will review the legal landscape surrounding the patient-physician relationship with a focus on when and how physicians can exercise their personal and professional autonomy in their clinical practice.

[Map of ethics conflicts in chronic patient's hospitalization]. / Mapa de conflictos éticos en hospitalización de pacientes crónicos.

The identification, priorization and anticipation of the ethics conflicts, allow the Healthcare Ethics Committees (HEC) a better approach to them, as well as the adoption of measures to prevent its appearance and/or its mitigation. For this purpose, we set ourselves the objective of knowing what they are in the present, how important they are, and what would be the future scenario to face. An qualitative structure research was made whit two focal groups whit the participation of nurses, nurse auxiliary and doctors from the hospitalization area, they also answer a future ethics conflicts Decalogue. The results were tested after by their importance level (Relevance-Frequency-Consistency). The medium age of the participants was 34,7 +- 15,4, whit a medium experience at work of 11,7 +- 15,4 years. A total of 40 ethics conflicts was identify grouped in 5 risk areas: professional, assistance, social, organizational and legal. From there 21 results the more important, between them we find patient abandonment, inexistence of internal performance protocols, patient and relatives false expectations waiting for non-assistance care, unnecessary care at the end of the life, lack of rules for family / caregivers, and ignorance of legality. The more important ethical dilemmas for the future identified by the personal will be patients in abandonment, the lack of sociohealth resources, conflicts with family / caregivers situation and lack of information for decision making at the end of the life. The ethical conflicts between the personal from a chronic patients hospital and the relatives/caregivers was identifying, the most important were prioritized, and futures were anticipated. In these scenarios, we highlight abandonment as the most important. A map of ethics conflicts is a good tool to identify risk areas for ethics conflicts, we see the difference between the ethics conflicts found in other kind of hospitals. The map of ethics conflicts need to be update periodically to keep the validity.

A Duty to treat? A Right to refrain? Bangladeshi physicians in moral dilemma during COVID-19.

BACKGROUND: Normally, physicians understand they have a duty to treat patients, and they perform accordingly consistent with codes of medical practice, standards of care, and inner moral motivation. In the case of COVID-19 pandemic in a developing country such as Bangladesh, however, the fact is that some physicians decline either to report for duty or to treat patients presenting with COVID-19 symptoms. At issue ethically is whether such medical practitioners are to be automatically disciplined for dereliction of duty and gross negligence; or, on the contrary, such physicians may legitimately claim a professional right of autonomous judgment, on the basis of which professional right they may justifiably decline to treat patients. METHODS: This ethical issue is examined with a view to providing some guidance and recommendations, insofar as the conditions of medical practice in an under-resourced country such as Bangladesh are vastly different from medical practice in an industrialized nation such as the USA. The concept of moral dilemma as discussed by philosopher Michael Shaw Perry and philosopher Immanuel Kant's views on moral appeal to "emergency" are considered pertinent to sorting through the moral conundrum of medical care during pandemic. RESULTS: Our analysis allows for conditional physician discretion in the decision to treat COVID-19 patients, i.e., in the absence of personal protective equipment (PPE) combined with claim of duty to family. Physicians are nonetheless expected to provide a minimum of initial clinical assessment and stabilization of a patient before initiating transfer of a patient to a "designated" COVID-19 hospital. The latter is to be done in coordination with the national center control room that can assure admission of a patient to a referral hospital prior to ambulance transport. CONCLUSIONS: The presence of a moral dilemma (i.e., conflict of obligations) in the pandemic situation of clinical care requires institutional authorities to exercise tolerance of individual physician moral decision about the duty to care. Hospital or government authority should respond to such decisions without introducing immediate sanction, such as suspension from all clinical duties or termination of licensure, and instead arrange for alternative clinical duties consistent with routine medical care.

Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of "Duty" for Health Practitioners.

From the ethics perspective, "duty of care" is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the "duty of care" from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of "duty" in their response to COVID-19.

The Charlie Gard Case, and the Ethics of Obstructing International Transfer of Seriously Ill Children.

In 2017, the court case over medical treatment of UK infant, Charlie Gard, reached global attention. In this article, I will analyze one of the more distinctive elements of the case. The UK courts concluded that treatment of Charlie Gard was not in his best interests and that it would be permissible to withdraw life-sustaining treatment. However, in addition, the court ruled that Charlie should not be transferred overseas for the treatment that his parents sought, even though specialists in Italy and the US were willing to provide that treatment. Is it ethical to prevent parents from pursuing life-prolonging treatment overseas for their children? If so, when is it ethical to do this? I will outline arguments in defense of obstructing transfer in some situations. I will argue, however, that this is only justified if there is good reason to think that the proposed treatment would cause harm.

Conscientious Objection in Healthcare: Neither a Negative Nor a Positive Right.

Conscientious objection in healthcare is often granted by many legislations regulating morally controversial medical procedures, such as abortion or medical assistance in dying. However, there is virtually no protection of positive claims of conscience, that is, of requests by healthcare professionals to provide certain services that they conscientiously believe ought to be provided, but that are ruled out by institutional policies. Positive claims of conscience have received comparatively little attention in academic debates. Some think that negative and positive claims of conscience deserve equal protection in terms of measures that institutions ought to take to accommodate them. However, in this issue of The Journal of Clinical Ethics (JCE), Abram Brummett argues against this symmetry thesis.1 He suggests that the relevant distinction is not between negative and positive claims of conscience, but between negative and positive rights of conscience. He argues that conscientious refusals and positive claims of conscience are both already protected as negative rights of conscience, but that this does not require institutions to accommodate positive claims of conscience. In this article I will argue that both Brummett and the authors he criticizes share a wrong view about the existence of conscience rights in healthcare. I will argue that there is no right to conscientious objection in healthcare, whether positive or negative. Thus, contra Brummett, I argue that the question whether such rights are positive or negative is as irrelevant as the question whether the claims of conscience are positive or negative.

Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.

BACKGROUND: Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources. RATIONALE: Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients. PRIORITISATION STRATEGY: Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount. PERSPECTIVE: Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.

Which Legal Approaches Help Limit Harms to Patients From Clinicians' Conscience-Based Refusals?

This article canvasses laws protecting clinicians' conscience and focuses on dilemmas that occur when a clinician refuses to perform a procedure consistent with the standard of care. In particular, the article focuses on patients' experience with a conscientiously objecting clinician at a secular institution, where patients are least likely to expect conscience-based care restrictions. After reviewing existing laws that protect clinicians' conscience, the article discusses limited legal remedies available to patients.

Limitation of life-sustaining treatment in NICU: Physicians' beliefs and attitudes in the Buenos Aires region.

OBJECTIVE: To explore the ethical beliefs and attitudes of Argentinean neonatologists regarding limitation of life-sustaining treatment (LST) for very sick infants. METHODS: We used an anonymous questionnaire including direct questions and hypothetical clinical cases (inevitable demise and anticipated survival with severe long-term disability). Multivariable analysis was carried out to assess the relation between type of clinical case and physicians' LST attitudes. RESULTS: Overall, 315 neonatologists in 34 units in the Buenos Aires region participated (response rate 54%). Most responders would agree with decisions to start or continue LST. In both clinical cases, continuing current treatment with no therapeutic escalation was the only form of LST limitation acceptable to a substantial proportion (about 60%) of neonatologists. Agreement with LST limitation was slightly but significantly more likely when death was inevitable. CONCLUSION: Argentinean neonatologists showed a conservative attitude regarding LST limitation. Patient prognosis and options of non-treatment decision significantly influenced their choices.