Conscientious Objection and the Anesthesiologist: An Ethical Dilemma.

Conscientious objection is a legally protected right of medical professionals to recuse themselves from patient care activities that conflict with their personal values. Anesthesiology is different from most specialties with respect to conscientious objection in that the focus is to facilitate safe, efficient, and successful performance of procedures by others, rather than to perform the treatment in question. This could give rise to a unique, somewhat indirect ethical tension between the application of conscientious objection and potential infringement upon patient autonomy and well-being. While some situations have clear grounds and precedent for conscientious objection (e.g., abortion, or futile procedures), newer procedures, such as gender-affirming surgery and xenotransplantation, may trigger conscientious objection for complex reasons. This review discusses ethical, legal, and practical aspects of conscientious objection; challenges to anesthesia groups, departments, and healthcare organizations when conscientious objection is invoked by anesthesiologists; and strategies to help mitigate the ethical dilemmas.

Patient-centered Engagement as a Mediator in the Associations of Healthcare Discrimination, Pain Care Denial, and Later Substance Use Among a Sample of Predominately African Americans Living with HIV.

Chronic pain is prevalent and often under-addressed among people with HIV and people who use drugs, likely compounding the stress of discrimination in healthcare, and self-medicating along with its associated overdose risk or other problematic coping. Due to challenges in treating pain and HIV in the context of substance use, collaborative, patient-centered patient-provider engagement (PCE) may be particularly important for mitigating the impact of pain on illicit drug use and promoting sustained recovery. We examined whether PCE with primary care provider (PCE-PCP) mediated the effects of pain, discrimination, and denial of prescription pain medication on later substance use for pain among a sample of 331 predominately African Americans with HIV and a drug use history in Baltimore, Maryland, USA. Baseline pain level was directly associated with a higher chance of substance use for pain at 12 months (Standardized Coefficient = 0.26, p < .01). Indirect paths were observed from baseline healthcare discrimination (Standardized Coefficient = 0.05, 95% CI=[0.01, 0.13]) and pain medication denial (Standardized Coefficient = 0.06, 95% CI=[0.01, 0.14]) to a higher chance of substance use for pain at 12 months. Effects of prior discrimination and pain medication denial on later self-medication were mediated through worse PCE-PCP at 6 months. Results underscore the importance of PCE interpersonal skills and integrative care models in addressing mistreatment in healthcare and substance use in this population. An integrated approach for treating pain and substance use disorders concurrently with HIV and other comorbidities is much needed. Interventions should target individuals at multiple risks of discriminations and healthcare professionals to promote PCE.

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.

Conscientious objection and barriers to abortion within a specific regional context - an expert interview study.

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.

Three Arguments Against Institutional Conscientious Objection, and Why They Are (Metaphysically) Unconvincing.

The past decade has seen a burgeoning of scholarly interest in conscientious objection in healthcare. While the literature to date has focused primarily on individual healthcare practitioners who object to participation in morally controversial procedures, in this article we consider a different albeit related issue, namely, whether publicly funded healthcare institutions should be required to provide morally controversial services such as abortions, emergency contraception, voluntary sterilizations, and voluntary euthanasia. Substantive debates about institutional responsibility have remained largely at the level of first-order ethical debate over medical practices which institutions have refused to offer; in this article, we argue that more fundamental questions about the metaphysics of institutions provide a neglected avenue for understanding the basis of institutional conscientious objection. To do so, we articulate a metaphysical model of institutional conscience, and consider three well-known arguments for undermining institutional conscientious objection in light of this model. We show how our metaphysical analysis of institutions creates difficulties for justifying sanctions on institutions that conscientiously object. Thus, we argue, questions about the metaphysics of institutions are deserving of serious attention from both critics and defenders of institutional conscientious objection.

Conscientious objection and the referral requirement as morally permissible moral mistakes.

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.

Do Clinicians Have a Duty to Participate in Pragmatic Clinical Trials?

Clinicians have good moral and professional reasons to contribute to pragmatic clinical trials (PCTs). We argue that clinicians have a defeasible duty to participate in this research that takes place in usual care settings and does not involve substantive deviation from their ordinary care practices. However, a variety of countervailing reasons may excuse clinicians from this duty in particular cases. Yet because there is a moral default in favor of participating, clinicians who wish to opt out of this research must justify their refusal. Reasons to refuse include that the trial is badly designed in some way, that the trial activities will violate the clinician's conscience, or that the trial will impose excessive burdens on the clinician.

Dignity, conscience and religious pluralism in healthcare: An argument for a presumption in favour of respect for religious belief.

Religious pluralism in healthcare means that conflicts regarding appropriate treatment can occur because of convictions of patients and healthcare workers alike. This contribution argues for a presumption in favour of respect for religious belief on the basis that such convictions are judgements of conscience, and respect for conscience is core to what it means to respect human dignity. The human person is a subject in relation to all that is. Human dignity refers to the worth of human persons as members of the species with capacities of reason and free choice that enable the realisation of dignity as self-worth through morally good behaviour. Conscience is both a feature of inherent dignity and necessary for acquiring dignity as self-worth. Conscience enables a person to identify objective values and disvalues for human flourishing, the rational capacity to reason about the relative importance of these values and the right way to achieve them and the judgement of the good end and the right means. Human persons are bound to follow their conscience because this is their subjective relationship to objective truth. Religious convictions are decisions of conscience because they are subjective judgements about objective truth. The presumption of respect for religious belief is limited by the normative dimension of human dignity such that a person's beliefs may be overridden if they objectively violate inherent dignity or morally legitimate acquired dignity.

Philosophical Failure and the Reasonability View of Conscientious Objection: Can Reason Adjudicate Metaphysical or Religious Claims?

Robert Card has proposed a reasonability view of conscientious objection that asks providers to state the reasons for their objection for evaluation and approval by a review board. Jason Marsh has challenged Card to provide explicit criteria for what makes a conscientious objection reasonable, which he claims will be too difficult a task given that such objections often involve contentious metaphysical or religious claims. Card has responded by outlining standards by which a conscientious objection could be judged reasonable. In this paper, I extend Marsh's critique to key concepts in the standards outlined by Card such as abortifacient, harm, emergency, and discrimination, showing they can be given radically different interpretations given different metaphysical or religious presumptions. To resolve these conflicting interpretations, a reasonability view of conscientious objection will need more than the criteria outlined by Card, it will need the resources to evaluate the reasonability of metaphysical or religious claims.

Development of the Inclination Toward Conscientious Objection Scale for Physicians.

This study aims to develop a valid and reliable scale to assess whether a physician is inclined to take conscientious objection when asked to perform medical services that clash with his/her personal beliefs. The scale, named the Inclination toward Conscientious Objection Scale, was developed for physicians in Turkey. Face validity, content validity, criterion-related validity, and construct validity of the scale were evaluated in the development process. While measuring criterion-related validity, Student's t-test was used to identify the groups that did and did not show inclination toward conscientious objection. There were 126 items in the initial item pool, which reduced to 42 after content validity evaluation by five experts. After necessary adjustments, the scale was administered to 224 participants. Both exploratory and confirmatory factor analyses were performed to investigate factor structure. The split-half method was employed to assess scale reliability, and the Spearman-Brown coefficient was calculated. Cronbach's alpha reliability coefficient was used to estimate the internal consistency of the scale items. The distinctiveness of the items was evaluated using Student's t-test. The lower and upper 27% groups were compared to assess the distinctiveness of the scale. The items were loaded on four factors that explained 85.46% of the variance: "Conscientious Objection - Medical Profession Relationship," "Conscientious Objection in Medical Education and Medical Practice," "Conscientious Objection with regard to the Concept of Rights" and "Conscientious Objection - Physician's Professional Identity and Role." The final scale has 40 items, and was found to be valid and reliable with high internal consistency.

Kantian Conscientious Objection: A Reply to Kennett.

In her paper, "The cost of conscience: Kant on conscience and conscientious objection," Jeanette Kennett argues that a Kantian view of conscientious objection in medicine would bar physicians from refusing to perform certain practices based on conscience. I offer a response in the following manner: First, I reconstruct her main argument; second, I present a more accurate picture of Kant's view of conscience. I conclude that, given a Kantian framework, a physician should be allowed to refuse to perform practices that break the moral law and, thus, refuse practices that violate her conscience.

Conscientious Objection and Institutional Objection to Voluntary Assistance in Dying: An Ethico-legal Critique.

This column examines conscientious objection and institutional objection in Australian voluntary assistance in dying. It reviews the current legislative regimes and then examines these practices from an ethical perspective, and raises particular concerns and suggestions with how conscientious objection and institutional objection should be operationalised.

Harmonizing conscience claims and patient access to assisted death.

The rights of patients to receive legally permissible interventions sometimes conflict with enshrined rights of providers to object, for reasons of conscience, to providing those interventions. Getting the balance right is challenging. But reasonable balance to manage these conflicting imperatives can be achieved in the design of programs for assisted death. Rather than limiting the discourse to the platform of competing individual rights, health leaders are urged to consider the broader societal benefits and impacts of valuing conscience in the practice of medicine, the creation of regulation and policy, and the delivery of healthcare. A method to determine that conscience claims are "genuine," "reasonable," and "acceptable" needs developing. A list of criteria toward this determination is offered.

Conscientious Objection to Providing Gender Health Care in Pediatric Training: Balancing the Vulnerability of Transgender Youth and the Vulnerability of Pediatric Residents.

Within pediatric graduate medical education, the care of transgender youth presents opportunities for deepening learners' understanding of equity, access, the role of the physician as an advocate, and health disparities caused by stigma and minority stress. However, when a pediatric resident objects to providing health care to this uniquely vulnerable population owing to their personal beliefs and values, how should pediatrician-educators respond? Important reasons to respect healthcare professionals' conscience have been described in the scholarly literature; however, equally important concerns have also been raised about the extent to which conscientious objection should be permitted in a pluralistic society, particularly given power differentials that favor healthcare professionals and grants them a monopoly over certain services. In the context of medical education, however, residents are in a unique position: they are simultaneously learners and employees, and although privileged relative to their patients, they are also vulnerable in relation to the hierarchy of healthcare and of institutions. We must find a compassionate balance between nurturing the evolving conscience of students and trainees and protecting the health and well-being of our most vulnerable patients. Educators have an obligation to foster empathy, mitigate bias, and mentor their learners, regardless of beliefs, but in some cases, they may recognize that there are limits: patients' welfare ultimately takes precedence and trainees should be guided toward alternative career paths. We explore the limits of conscientious objection in medical training and propose a framework for pediatrician-educators to support learners and patients in challenging circumstances.

Are conscientious objectors morally obligated to refer?

In this paper, we argue that providers who conscientiously refuse to provide legal and professionally accepted medical care are not always morally required to refer their patients to willing providers. Indeed, we will argue that refusing to refer is morally admirable in certain instances. In making the case, we show that belief in a sweeping moral duty to refer depends on an implicit assumption that the procedures sanctioned by legal and professional norms are ethically permissible. Focusing on examples of female genital cutting, clitoridectomy and 'normalizing' surgery for children with intersex traits, we argue that this assumption is untenable and that providers are not morally required to refer when refusing to perform genuinely unethical procedures. The fact that acceptance of our thesis would force us to face the challenge of distinguishing between ethical and unethical medical practices is a virtue. This is the central task of medical ethics, and we must confront it rather than evade it.

Junior doctors and conscientious objection to voluntary assisted dying: ethical complexity in practice.

In jurisdictions where voluntary assisted dying (VAD) 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.

What is special about conscientious objection?

The deliverances of our conscience are heartfelt, but not necessarily reason-based, moral convictions that concern our own behaviour. The fact that conscientious objections to a regulation, like a prohibition or obligation, express a heartfelt conviction that it is morally wrong to comply or morally permissible not to comply with the regulation provides a moral reason to respect the conviction because failing to do so is likely to cause objectors considerable suffering. But for conscientious objections to succeed in justifying exempting objectors from complying with the regulation, the suffering caused by forcing compliance must outweigh the suffering produced by exempting them from compliance. In the case of obligations, this necessitates that others with a similar competence are available to replace them. Conscientious objectors can never justifiably demand to be granted exemptions. This takes acts of generosity made feasible by favourable circumstances, such as the availability of replacements.

Conscientious objections, the nature of medicine, and the need for reformability.

The debate over whether the medical profession should accommodate its members' conscientious objections (COs) has raged on in the bioethics literature and on legislative floors for decades. Unfortunately, participants on all sides of the debate fail to distinguish among different types of CO, a failure that obstructs the view of which cases warrant accommodation and why. In this paper, we identify one type of CO that warrants consideration for accommodation, called Nature of Medicine COs (NoMCOs). NoMCOs involve the refusal of physicians to perform actions they reasonably judge to be contrary to the nature of medicine and their professional obligations. We argue that accommodating NoMCOs can be justified based on the profession's need to preserve reformability. Importantly, this previously underdeveloped position evades some of the concerns commonly raised by opponents of CO accommodations.

A defense of conscientious objection: Why health is integral to the permissibility of medical refusals.

Schuklenk, Smalling, and Savulescu put forth four conditions that delineate when conscientious objection is impermissible. Roughly, they argue for the following claim: if some practice is legal, standard, expected of a profession, and in the patient's interest, then medical professionals cannot refuse to perform the practice. In this essay, I argue that these conditions are not jointly sufficient to deny medical professionals the ability to refuse to perform procedures that detract from a patient's health. They are insufficient to bar medical refusals to perform certain practices because, even when these conditions are met, non-health conducive practices would not be open to refusal by the physician. I provide an example of a non-health conducive practice female genital mutilation, which meets all of the proposed conditions but, intuitively, should be open to medical refusals. As a result, I conclude that the proposed conditions are insufficient to determine when conscientious objection is impermissible. I then offer an amendment to their position by suggesting that a practice, in addition to the other four conditions, must also be health conducive in order to remove the medical professional's ability to refuse to perform the practice.

Attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience clause.

BACKGROUND: While healthcare professionals' right to invoke the conscience clause has been recognised as a fundamental human right, it continues to provoke a heated debate in Polish society. Although public discourse is filled with ethical and legal considerations on the conscience clause, much less is known about the attitudes of healthcare professionals regarding that matter. The aim of this study was therefore to describe the attitudes of Polish physicians, nurses and pharmacists towards the ethical and legal aspects of the conscience clause. METHODS: We analysed a group of three hundred healthcare professionals: physicians, nurses and pharmacists in Poznan, Poland, using a standard questionnaire comprising of 29 questions about various ethical and legal aspects of the conscience clause and participants' personal experiences with the conscience clause. The study was conducted between January and March 2020. RESULTS: This research shows that although most Polish healthcare workers support the right to invoke the conscience clause they differ significantly in their opinions on to whom and to what medical procedures the conscience clause should apply to. It also demonstrated that while the conscience clause is rarely invoked in Poland, most healthcare professionals declare that the current legal regulations in that sphere are unclear and inaccurate. CONCLUSIONS: While there is an urgent need to raise the awareness regarding the conscience clause among medical students and healthcare professionals and educate them about such issues, it is even more important to improve the legal system in regard to the CC so that it protects both HCPs' right to the CC and safeguards patients' rights to medical services.