An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

Pharmacies, pharmacists, and conscientious objection.

This paper examines the obligations of pharmacy licensees and pharmacists in the context of conscience-based objections to filling lawful prescriptions for certain types of medications--e.g., standard and emergency contraceptives. Claims of conscience are analyzed as means to preserve or maintain an individual's moral integrity. It is argued that pharmacy licensees have an obligation to dispense prescription medications that satisfy the health needs of the populations they serve, and this obligation can override claims of conscience. Although efforts should be made to respect the moral integrity of pharmacists and accommodate their claims of conscience, it is argued that the health needs of patients and the professional obligations of pharmacists limit the extent to which pharmacists may refuse to assist patients who have lawful prescriptions for medically indicated drugs.

A response to Brock and Skene.

KIE: Wicclair responds briefly to articles by Dan W. Brock, "Patient decision-making competence and risk," and Loane Skene, "Risk-related standard inevitable in assessing competence," in this issue of Bioethics. Brock and Skene were responding to Wicclair's essay, "Decision-making capacity and risk," also in this issue of Bioethics. Wicclair had critiqued the arguments of Brock and Allen Buchanan, published elsewhere, concerning standards of competence for health care treatment decision making.^ieng

Patient decision-making capacity and risk.

KIE: Although certain requisites of patient decision-making competency are generally agreed upon, there is no universally recognized standard. Wicclair, of the University of West Virginia Department of Philosophy, offers two reasons why a single standard should not be determined. First, competency is variable according to the decision at hand, i.e., task-related. Second, arguments in support of risk-related criteria fail. Wicclair challenges claims that a risk-related standard is legally the most feasible, is supported by the doctrine of informed consent, is consistent with everyday competence judgments, and achieves the best compromise between patient autonomy and concern for patient well-being. He argues that where risk is high, such a standard threatens unattainable requirements for competency; and where it is low, offers no set minimum, resulting in overly weak competency standards. Wicclair concludes that the standard of decision-making capacity should not vary by risk perceived.^ieng