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Professionalism and the Ethics of Conscientious Objection Accommodation in Medicine

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Abstract

Some health-care professionals refuse to perform certain services because doing so would violate their conscientiously held beliefs. Arguments for and against their accommodation claims continue both in the public square and in the courts, as well as in bioethics. This chapter introduces this debate by discussing jurisdictions in which accommodation is granted. We offer evidence of the detrimental effects it has on access to health-care services. An overview of influential ethical arguments for and against conscientious objection accommodation, including but not limited to the incompatibility thesis and the moral integrity defense, is presented. We conclude with a discussion of arguments based on the values of diversity and equality of opportunity.

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Notes

  1. 1.

    Mark Wicclair, “Conscientious objection in medicine,” Bioethics 14, no. 3 (July 2000): 205–227.

  2. 2.

    Jane Harries, Diane Cooper, Anna Strebel, and Christopher J Colvin, “Conscientious objection and its impact on abortion service provision in South Africa: a qualitative study,” Reproductive Health 11, no. 16 (February 2014): 16. doi: https://doi.org/10.1186/1742-4755-11-16

  3. 3.

    Wendy Chavkin, Liddy Leitman, Kate Polin, “Conscientious objection and refusal to provide reproductive healthcare: A White Paper examining prevalence, health consequences, and policy responses,” International Journal of Gynecology and Obstetrics 123 (December 2013): 541–556.

  4. 4.

    Francesca Minerva. “Conscientious Objection in Italy,” Journal of Medical Ethics 41 (2015): 170–3.

  5. 5.

    International Covenant on Civil and Political Rights, adopted December 16, 1966, General Assembly Resolution 2200A(XXI), United Nations GAOR, 21st Session, Supp. No. 16, at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171.

  6. 6.

    Canadian Charter of Rights and Freedoms, s 2a-2b, Part I of the Constitution Act, 1982, being Schedule B to the Canada Act 1982 (UK), 1982, c 11.

  7. 7.

    Reynolds v. United States, 98 U.S. 145 (1878).

  8. 8.

    Douglas NeJaime and Reva B. Siegel, “Conscience Wars: Complicity-Based Conscience Claims in Religion and Politics,” Yale Law Journal 124, no. 7 (May 2015): 2516–2591, at 2566.

  9. 9.

    Pichon and Sajous v France, 2001-X Eur. Ct. H.R.

  10. 10.

    Christina Zampas and Ximena Andión-Ibañez, “Conscientious Objection to Sexual and Reproductive Health Services: International Human Rights Standards and European Law and Practice,” European Journal of Health Law 19 (2012): 231–256, at 241.

  11. 11.

    NeJaime and Siegel, “Conscience Wars: Complicity-Based Conscience Claims,” 2533.

  12. 12.

    Zampas, C, Ximena, A-I (2012), Ibid.

  13. 13.

    Roger Trigg, “Conscientious Objection and ‘Effective Referral’,” Cambridge Quarterly of Healthcare Ethics 26, no. 1 (December 2016): 32–43.

  14. 14.

    Christian Munthe, “Conscientious refusal in healthcare: the Swedish solution,” Journal of Medical Ethics 43 (September 2016): 257–259.

  15. 15.

    Chavkin, Leitman, and Polin, “Conscientious objection and refusal to provide reproductive healthcare,” 541–556.

  16. 16.

    Douglas NeJaime and Reva Siegel, “Conscience Wars in Transnational Perspective: Religious Liberty, Third-Party Harm, and Pluralism,” in The Conscience Wars: Rethinking the Balance Between Religion, Identity, and Equality, eds. Susanna Mancini and Michael Rosenfeld (Cambridge: Cambridge University Press, forthcoming).

  17. 17.

    Edmund Pellegrino, “The physician’s conscience, conscience clauses, and religious belief: a Catholic perspective,” Fordham Urban Law Journal 30 (November 2002): 221–44.

  18. 18.

    Daniel Weinstock, “Conscientious refusal and healthcare professionals: does religion make a difference?” Bioethics 28, no. 1 (January 2014)L: 8–15.

  19. 19.

    James F. Childress, “Appeals to Conscience,” Ethics 74, no.4 (July 1979): 315–335.

  20. 20.

    Daniel P. Sulmasy, “What is conscience, and why is respect for it so important?” Theoretical Medicine and Bioethics 29, no. 3 (June 2008): 135–4.

  21. 21.

    Mark Wicclair, Conscientious Objection in Health Care: An Ethical Analysis (Cambridge: Cambridge University Press, 2011).

  22. 22.

    Mark Wicclair, “Conscientious Objection in Healthcare and Moral Integrity,” Cambridge Quarterly of Healthcare Ethics 26, no. 1 (December 2016): 7–17.

  23. 23.

    Ibid.

  24. 24.

    Robert Card, “Conscientious Objection and Emergency Contraception,” The American Journal of Bioethics 7, no. 6 (June 2007): 8–14.

  25. 25.

    Robert Card, “The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine,” Cambridge Quarterly of Healthcare Ethics 26, no. 1 (December 2016): 82–96.

  26. 26.

    Robert Card, “Reasonability and conscientious objection: a reply to Marsh and an elaboration of the reason-giving requirement,” Bioethics 28, no. 6 (July 2014): 320–326.

  27. 27.

    Alida Liberman, “Wrongness, responsibility, and conscientious refusal in health care,” Bioethics 31, no. 7 (September 2017): 495–504.

  28. 28.

    Wicclair, “Conscientious Objection in Healthcare and Moral Integrity,” 13.

  29. 29.

    Trigg, “Conscientious Objection,” 40.

  30. 30.

    Jason Marsh, “Conscientious refusals and reason-giving,” Bioethics 28, no. 6 (July 2014): 313–319, at 316.

  31. 31.

    Ibid., at 317.

  32. 32.

    Benjamin Zolf, “No Conscientious Objection without Normative Justification: Against Conscientious Objection in Medicine,” Bioethics 2018 (in press). 

  33. 33.

    Smith: Employment Division, Department of Human Resources of Oregon v. Smith, [1990] 494 US 872.

  34. 34.

    Amselem: Syndicat Northcrest v Amselem, [2004] 2 SCR 551 2004 SCC 47.

  35. 35.

    Kelly Grant, “Canadian doctors turn away from assisted dying over fees,” Globe and Mail, July 3, 2017, https://beta.theglobeandmail.com/news/national/payment-complications-turning-canadian-doctors-away-from-assisted-dying/article35538666/ [Accessed October 29, 2017].

  36. 36.

    Christopher Meyers and Robert D. Woods, “Conscientious objection? Yes, but make sure it is genuine,” The American Journal of Bioethics 7, no. 6 (June 2007): 19–20.

  37. 37.

    Lori Kantymir and Carolyn Mcleod, “Justification for Conscience Exemptions in Health Care,” Bioethics 28, no. 1 (September 2013): 16–23.

  38. 38.

    Udo Schuklenk and Ricardo Smalling, “Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies,” Journal of Medical Ethics 43, no. 4 (April 2017): 234–240.

  39. 39.

    Jocelyn Maclure and Isabelle Dumont, “Selling conscience short: a response to Schuklenk and Smalling on conscientious objections by medical professionals,” Journal of Medical Ethics 43, no. 4 (April 2017): 241–244.

  40. 40.

    Schuklenk and Smalling, “Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies,” 236.

  41. 41.

    Julian Savulescu, “Conscientious objection in medicine,” British Medical Journal 332, (February 2006): 294–297.

  42. 42.

    Julian Savulescu and Udo Schuklenk, “Doctors have no right to refuse medical assistance in dying, abortion, or contraception,” Bioethics 31, no. 3 (March 2017): 162–170.

  43. 43.

    Rosamond Rhodes, “The ethical standard of care,” American Journal of Bioethics 6, no. 2 (August 2006): 76–78.

  44. 44.

    Ibid., 77.

  45. 45.

    Savulescu and Schuklenk, “Doctors have no right to refuse,” 162–170.

  46. 46.

    Schuklenk and Smalling, “Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies,” 234.

  47. 47.

    Christopher Cowley, “A defence of conscientious objection in medicine: a reply to Schuklenk and Savulescu,” Bioethics 30, no. 5 (June 2016): 358–364.

  48. 48.

    Christian Munthe, “Conscientious refusal in healthcare,” 257–259.

  49. 49.

    Mark Wicclair, (2008) “Is conscientious objection incompatible with a physician’s professional obligations?” Theoretical Medicine and Bioethics 29, no. 3 (June 2008): 171–185.

  50. 50.

    Trigg, “Conscientious Objection,” 32–43.

  51. 51.

    Ibid., 34.

  52. 52.

    Jeff Blackmer, “Clarification of the CMA’s position concerning induced abortion,” Canadian Medical Association Journal 176, no. 9 (April 2007): 1310.

  53. 53.

    American Medical Association Council on Ethics and Judicial Affairs (2014) Physician Exercise of Conscience. https://www.ama-assn.org/sites/default/files/media-browser/public/about-ama/councils/Council%20Reports/council-on-ethics-and-judicial-affairs/i14-ceja-physician-exercise-conscience.pdf [Accessed October 29, 2017].

  54. 54.

    NeJaime and Siegel, “Conscience wars: Complicity-Based Conscience Claims,” 2566–7.

  55. 55.

    Jonathan Hughes, “Conscientious objection, professional duty and compromise: A response to Savulescu and Schuklenk,” Bioethics 32, no. 1 (February 2018): 126–131. https://doi.org/10.1111/bioe.12410

  56. 56.

    Maclure and Dumont, “Selling conscience short,” 243.

  57. 57.

    Schuklenk and Smalling, “Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies,” 239.

  58. 58.

    Daniel P. Sulmasy, “Tolerance, professional judgment, and the discretionary space of the physician,” Cambridge Quarterly of Healthcare Ethics 26, no. 1 (December 2016): 22.

  59. 59.

    Trigg, “Conscientious Objection,” 34.

  60. 60.

    Savulescu and Schuklenk, “Doctors have no right to refuse,” 166.

  61. 61.

    Richard John Lyus, “Response to: ‘Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies’ by Schuklenk and Smalling,” Journal of Medical Ethics 43, no. 4 (April 2017): 250–252.

  62. 62.

    Udo Schuklenk and Ricardo Smalling, “Against the accommodation of subjective healthcare provider beliefs in medicine: counteracting supporters of conscientious objector accommodation arguments,” Journal of Medical Ethics 43, no. 4 (April 2017): 253–256, at 255.

  63. 63.

    Ibid., at 256.

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Schuklenk, U., Zolf, B. (2018). Professionalism and the Ethics of Conscientious Objection Accommodation in Medicine. In: Boonin, D. (eds) The Palgrave Handbook of Philosophy and Public Policy. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-93907-0_46

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