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.

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.

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.

Conscientious Objection: A Talmudic Paradigm Shift

Conscientious objection remains a very heated topic with strong opinions arguing for and against its utilization in contemporary health care. This paper summarizes and analyzes various arguments in the bioethical literature, favoring and opposing conscientious objection, as well as some of the proposed solutions and compromises. I then present a paradigm shifting compromise approach that arises out of very recent Jewish bioethical thought that refocuses the discussion and can minimize the frequency with which conscientious objection is required.

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.

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one's conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.

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.

Conscience, tolerance, and pluralism in health care

Increasingly, physicians are being asked to provide technical services that many (in some cases, most) believe are morally wrong or inconsistent with their beliefs about the meaning and purposes of medicine. This controversy has sparked persistent debate over whether practitioners should be permitted to decline participation in a variety of legal practices, most notably physician-assisted suicide and abortion. These debates have become heavily politicized, and some of the key words and phrases are being used without a clear understanding of their meaning. In this essay, I endeavor, firstly, to clarify the meaning of some of these terms: conscience, conscientious action, professional judgment, conscientious objection, conscience clauses, civil disobedience, and tolerance. I argue that use of the term conscientious objection to describe these refusals by health care professionals is mistaken and confusing. Secondly, relying on a proper understanding of the moral and technical character of medical judgment, the optimal deference that the state and markets ought to have toward professions, and general principles of Lockean tolerance for a diversity of practices and persons in a flourishing, pluralistic, democratic society, I offer a defense of tolerance with respect to the deeply held convictions of physicians and other health care professionals who hold minority views on contested but legal medical practices.

Conscience, conscientious objections, and medicine

To inform the ongoing discussion of whether claims of conscientious objection allow medical professionals to refuse to perform tasks that would otherwise be their duty, this paper begins with a review of the philosophical literature that describes conscience as either a moral sense or the dictate of reason. Even though authors have starkly different views on what conscience is, advocates of both approaches agree that conscience should be obeyed and that keeping promises is a conscience-given moral imperative. The paper then considers exemplars of conscientious objection-Henry David Thoreau, Mohandas Gandhi, and Martin Luther King Jr.-to identify the critical feature of conscientious objection as willingness to bear the burdens of one's convictions. It concludes by showing that medical professionals who put their own interests before their patients' welfare violate their previous commitments and misappropriate the title "conscientious objector" because they are unwilling to bear the burdens of their choices and instead impose burdens on their patients and colleagues.

Protecting reasonable conscientious refusals in health care

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.

Conscience-based refusal of patient care in medicine: a consequentialist analysis

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.

Preventing conscientious objection in medicine from running amok: a defense of reasonable accommodation

A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care (2019), and a proposed bill in the British House of Lords, the Conscientious Objection (Medical Activities) Bill (2017), may well warrant a concern that-to borrow a phrase Daniel Callahan applied to self-determination-conscientious objection in health care has "run amok." Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated "conscience absolutism." There are two common strategies to counter conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation.

Medical Acts and Conscientious Objection: What Can a Physician be Compelled to Do?

A key question has been underexplored in the literature on conscientious objection: if a physician is required to perform 'medical activities,' what is a medical activity? This paper explores the question by employing a teleological evaluation of medicine and examining the analogy of military conscripts, commonly cited in the conscientious objection debate. It argues that physicians (and other healthcare professionals) can only be expected to perform and support medical acts - acts directed towards their patients' health. That is, physicians cannot be forced to provide or support services that are not medical in nature, even if such activities support other socially desirable pursuits. This does not necessarily mean that medical professionals cannot or should not provide non-medical services, but only that they are under no obligation to provide them.

What are the ethical and legal considerations when your patient refuses the standard of care?

In medical practice, physicians are sometimes faced with patients who reject the gold-standard treatment for a condition. In this hypothetical clinical scenario, we present the case of a patient who refuses Mohs micrographic surgery for management of infiltrative basal cell carcinoma and instead requests off-label therapy with imiquimod. We discuss the treating dermatologist's options in response to this patient's request and the ethical considerations surrounding the case. We conclude that the physician has the right to refuse to provide treatment that deviates from standard clinical practice but that the physician should counsel the patient on all options, provide thorough informed consent, offer contact information for the patient to pursue a second opinion or a radiation oncology referral, and ensure safe transfer of care should the patient desire treatment with a different provider.

Ethical position of medical practitioners who refuse to treat unvaccinated children

Recent reports in Australia have suggested that some medical practitioners are refusing to treat children who have not been vaccinated, a practice that has been observed in the USA and parts of Europe for some years. This behaviour, if it is indeed occurring in Australia, has not been supported by the Australian Medical Association, although there is broad support for medical practitioners in general having the right to conscientious objection. This paper examines the ethical underpinnings of conscientious objection and whether the right to conscientious objection can be applied to the refusal to treat unvaccinated children. The implications of such a decision will also be discussed, to assess whether refusal to treat unvaccinated children is ethically justifiable. The best interests of both existing and new patients are crucially important in a doctor's practice, and the tension between these two groups of patients are contemplated in the arguments below. It is argued that on balance, the refusal to treat unvaccinated children constitutes unjustified discrimination.

Internal morality of medicine and physician autonomy

Robert Veatch and others have questioned whether there are internal moral rules of medicine. This paper examines the legal regulatory model for governing professions as the autonomous exercise of professional skills and asks whether there is a theoretical basis for this model. Taking John Rawls's distinction between the justification of a practice and justification of the rules internal to the practice, this paper argues that the autonomous exercise of professional skills is justified so long as it benefits society. In opposition to Christopher Boorse, it is argued that medicine is pathocentric and that physicians exercise skills in treating pathologies. The autonomous treatment of pathologies is justified because non-interference with physicians will lead to greater treatment of pathologies and so benefit society. Finally, the analysis of medicine as the autonomous exercise of skills in treating pathologies yields the rule that physicians not be forced to cause pathologies.

The Market View on conscientious objection: overvalued

Ancell and Sinnott-Armstrong argue that medical providers possess wide freedoms to determine the scope of their practice, and therefore, prohibiting almost any conscientious objections is a bad idea. They maintain that we could create an acceptable system on the whole which even grants accommodations to discriminatory refusals by healthcare professionals. Their argument is premised upon applying a free market mechanism to conscientious objections in medicine, yet I argue their Market View possesses a number of absurd and troubling implications. Furthermore, I demonstrate that the fundamental logic of their main argument is flawed. Thinkers who wish to address the issues raised in this debate in general or by discriminatory conscience objections in particular should avoid the Market View and instead envisage theories that assess the reasons underlying conscientious refusals in medicine.

[Subfertility in mentally disabled people who desire to have children: how to give balanced advice]

When people with a mental disability fail to conceive naturally, they also like to be considered for fertility treatment. However, the GP, gynaecologist or fertility specialist may question their parenting competence. Physicians may and can refuse fertility treatment if they have reasons to suspect that the child will have a poor quality of life. We are using a case history to outline how a well-considered multidisciplinary recommendation can be made that does justice to the patient's request while causing the least amount of grief. The guiding principle in doing so is the moral consideration that the harm to the future child should not outweigh the harm to the parents.

Withholding and withdrawing treatment for cost-effectiveness reasons: Are they ethically on par?

In healthcare priority settings, early access to treatment before reimbursement decisions gives rise to problems of whether negative decisions for cost-effectiveness reasons should result in withdrawing treatment, already accessed by patients. Among professionals there seems to be a strong attitude to distinguish between withdrawing and withholding treatment, viewing the former as ethically worse. In this article the distinction between withdrawing and withholding treatment for reasons of cost effectiveness is explored by analysing the doing/allowing distinction, different theories of justice, consequentialist and virtue perspectives. The authors do not find any strong reasons for an intrinsic difference, but do find some reasons for a consequentialist difference, given present attitudes. However, overall, such a difference does not, all things considered, provide a convincing reason against withdrawal, given the greater consequentialist gain of using cost-effective treatment. As a result, patients should be properly informed when given early access to treatment, that such treatment can be later withdrawn following a negative reimbursement decision.

No conscientious objection without normative justification: Against conscientious objection in medicine

Most proponents of conscientious objection accommodation in medicine acknowledge that not all conscientious beliefs can justify refusing service to a patient. Accordingly, they admit that constraints must be placed on the practice of conscientious objection. I argue that one such constraint must be an assessment of the reasonability of the conscientious claim in question, and that this requires normative justification of the claim. Some advocates of conscientious object protest that, since conscientious claims are a manifestation of personal beliefs, they cannot be subject to this kind of public justification. In order to preserve an element of constraint without requiring normative justification of conscientious beliefs, they shift the justificatory burden from the belief motivating the conscientious claim to the condition of the patient being refused service. This generally involves a claim along the lines that conscientious refusals should be permitted to the extent that they do not cause unwarranted harm to the patient. I argue that explaining what would constitute warranted harm requires an explanation of what it is about the conscientious claim that makes the harm warranted. 'Warranted' is a normative operator, and providing this explanation is the same as providing normative justification for the conscientious claim. This shows that resorting to facts about the patient's condition does not avoid the problem of providing normative justification, and that the onus remains on advocates of conscientious objection to provide normative justification for the practice in the context of medical care.

Conscientious objection in healthcare: How much discretionary space best supports good medicine?

Daniel Sulmasy has recently argued that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences. The only constraints Sulmasy believes we should place on physicians' discretionary space are those defined by a form of tolerance he derives from Locke, whereby people can publicly act in accordance with their personal religious and moral beliefs as long as their actions are not destructive to society. Sulmasy also claims that those who would reject physicians' right to conscientious objection eliminate discretionary space, thus undermining good medicine and unnecessarily limiting religious freedom. I argue that, although Sulmasy is correct that some discretionary space is necessary for good medicine, he is wrong in thinking that proscribing conscientious objection entails eliminating discretionary space. I illustrate this using Julian Savulescu and Udo Schuklenk's system for restricting conscientious objections as a counter-example. I then argue that a narrow discretionary space constrained by professional ideals will promote good medicine better than Sulmasy's wider discretionary space constrained by his conception of tolerance. Sulmasy's version of discretionary space would have us tolerate actions that are at odds with aspects of good medicine, including aspects that Sulmasy himself explicitly values, such as fiduciary duty. Therefore, if we want the degree of religious freedom in the public sphere that Sulmasy favours then we must decide whether it is worth the cost to the healthcare system.

Sanitary Worker's Death Unnerves Pakistan's Health Care Ethics to the Core

Health care ethics is a sensitive domain, which if ignored, can lead to patient dissatisfaction, weakened doctor-patient interaction and episodes of violence. Little importance has been paid to medical ethics within undergraduate medical education in developing countries such as Pakistan. Three doctors in Pakistan are currently facing an official police complaint and arrest charges, following the death of a sanitary worker, who fell unconscious while cleaning a drain and was allegedly refused treatment as he was covered in sewage filth. The medical license of the doctors in question should be cancelled, if found guilty following a thorough investigation into the case. The 'right to life' has been universally assured by all moral, cultural and legal codes and no society can ever argue against the sacredness of a human life. It is quite clear that the aforesaid doctors' actions are not only against the core principles of the physicians' code, but also go against the doctrine of human rights. If serious efforts on an urgent basis are not made by the regulatory and governing bodies, one can definitely expect similar incidents for at least a few more decades before any noticeable change is seen.

Learning about Teaching

There are three broad themes in this issue of the Hastings Center Report. First, a special report published as a supplement to the issue addresses the medical and health policy issues faced by lesbian, gay, bisexual, and transgender patients. Inside the issue, the two articles take up questions about how caregivers may justify a refusal to provide a medical service that a patient has requested. The issue also contains a set of essays that have emerged from a collaborative effort by The Hastings Center and the Presidential Commission for the Study of Bioethical Issues to promote scholarly engagement with the practical problem of teaching caregivers, researchers, scientists, and others to address bioethical problems. What appears here is the first installment of a series that will appear in the pages of the Report well into the 2015 volume.

Provider Conscientious Refusal of Abortion, Obstetrical Emergencies, and Criminal Homicide Law

Catholic doctrine's strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials.

Conscience claims, metaphysics, and avoiding an LGBT eugenic

Novel assisted reproductive technologies (ART) are poised to present our society with strange new ethical questions, such as whether lesbian, gay, bisexual, and transgender (LGBT) couples should be allowed to produce children biologically related to both parents, or whether trans-women who want to experience childbirth should be allowed to receive uterine transplants. Clinicians opposed to offering such technologies to LGBT couples on moral grounds are likely to seek legal shelter through the conscience clauses enshrined in U.S. law. This paper begins by briefly discussing some novel ART on the horizon and noting that it is unclear whether current conscience clauses will permit fertility clinics to deny such services to LGBT individuals. A compromise approach to conscience is any view that sees the value of respecting conscience claims within limits. I describe and critique the constraints proposed in the recent work of Wicclair, NeJaime and Siegel as ultimately begging the question. My purpose is to strengthen their arguments by suggesting that in the controversial situations that elicit claims of conscience, bioethicists should engage with the metaphysical claims in play. I argue that conscience claims against LGBT individuals ought to be constrained because the underlying metaphysic-that God has decreed the LGBT lifestyle to be sinful-is highly implausible from the perspective of a naturalized metaphysic, which ought to be the lens through which we evaluate conscience claims.

A Morally Permissible Moral Mistake? Reinterpreting a Thought Experiment as Proof of Concept

This paper takes the philosophical notion of suberogatory acts or morally permissible moral mistakes and, via a reinterpretation of a thought experiment from the medical ethics literature, offers an initial demonstration of their relevance to the field of medical ethics. That is, at least in regards to this case, we demonstrate that the concept of morally permissible moral mistakes has a bearing on medical decision-making. We therefore suggest that these concepts may have broader importance for the discourse on medical ethics and should receive fuller consideration by those working the field. The focus of the discussion we present is on a particular thought experiment originally presented by Sulmasy and Sugarman. Their case formed the basis of an exchange about the moral equivalence of withdrawing and withholding life-saving treatment. The analysis Sulmasy and Sugarman set out is significant because, contrary to common bioethical opinion, it implies that the difference between withdrawing and withholding life-saving treatment holds, rather than lacks, moral significance. Following a brief discussion of rejoinders to Sulmasy and Sugarman's article, we present a constructive reinterpretation of the thought experiment, one that draws on the idea of suberogatory acts or "morally permissible moral mistakes." Our analysis, or so we suggest, accounts for the differing moral intuitions that the case prompts. However, it also calls into question the degree to which this thought experiment can be thought of as illustrating the moral (non)equivalence of withdrawing and withholding life-saving treatment. Rather, we conclude that it primarily illuminates something about the ethical parameters of healthcare when family members, particularly parents, are involved in decision-making.

A critical review of conscientious objection and decriminalisation of abortion in Chile

From 1989 through September 2017, Chile's highly restrictive abortion laws exposed women to victimisation and needlessly threatened their health, freedom and even lives. However, after decades of unsuccessful attempts to decriminalise abortion, legislation regulating pregnancy termination on three grounds was recently enacted. In the aftermath, an aggressive conservative drive designed to turn conscientious objection into a pivotal new obstacle, mounted during the congressional debate, has led to extensive, complex arguments about the validity and legitimacy of conscientious objection. This article offers a critical review of the emergence of conscientious objection and its likely policy and ethical implications. It posits the need to regulate conscientious objection through checks and balances designed to keep it from being turned into an ideological barrier meant to hinder women's access to critical healthcare.

Conscientious objection and person-centered care

Person-centered care offers a promising way to manage clinicians' conscientious objection to providing services they consider morally wrong. Health care centered on persons, rather than patients, recognizes clinicians and patients on the same stratum. The moral interests of clinicians, as persons, thus warrant as much consideration as those of other persons, including patients. Interconnected moral interests of clinicians, patients, and society construct the clinician as a socially embedded and integrated self, transcending the simplistic duality of private conscience versus public role expectations. In this milieu of blurred boundaries, person-centered care offers a constructive way to accommodate conscientious objection by clinicians. The constitutionally social nature of clinicians commits and enables them, through care mechanisms such as self-care, to optimize the quality of health care and protect the welfare of patients. To advance these conditions, it is recommended that the medical profession develop a person-centered culture of care, along with clinician virtues and skills for person-centered communication.

Families' Sense of Abandonment When Patients Are Referred to Hospice

BACKGROUND

Terminally ill patients with cancer and their families may have a sense of abandonment when they are referred to hospice. This study aimed to clarify the prevalence of families' sense of abandonment, explore the association between the sense of abandonment and the oncologists' behaviors, and investigate the association between the sense of abandonment and the families' depression and complicated grief.

PATIENTS AND METHODS

This was part of a nationwide self-reported questionnaire survey of bereaved families of patients with cancer who died in inpatient hospices. We sent questionnaires to 947 bereaved families of patients with cancer who died in 133 certified hospices between May 2012 and January 2014.

RESULTS

Among 707 responses obtained, a total of 189 (26.7%) families felt abandoned. The factors significantly associated with a greater sense of abandonment were that the oncologists said there was nothing more to do for the patient, the patient's age of less than 60 years, and being the patient's spouse. The factors significantly associated with a lower sense of abandonment were that the oncologists reassured the patients that they had received the best anticancer treatment, that the oncologists recommended hospices as one potential choice rather than mandatory, and that a palliative care team provided care. Families with a sense of abandonment had higher scores on the Patient Health Questionnaire-9 (p = .096) and Brief Grief Questionnaire (p < .001).

CONCLUSION

Approximately a quarter of bereaved families had a sense of abandonment, which was associated with a higher rate of complicated grief. Oncologists may reduce the sense of abandonment by reassuring that the patients received the best anticancer treatment, recommending hospices as a potential choice rather than as mandatory, and by not saying there is nothing that can be done for the patients.

IMPLICATIONS FOR PRACTICE

This self-reported questionnaire study investigated the prevalence of families' feelings of abandonment when they were referred to hospice care, focusing on the association of sense of abandonment and the behavior of their physicians. Nearly a quarter of families felt abandoned by the referral to hospice, and the behavior of some oncologists was associated with the sense of abandonment.

Freedom of conscience in Europe? An analysis of three cases of midwives with conscientious objection to abortion

While abortion has been legal in most developed countries for many years, the topic remains controversial. A major area of controversy concerns women's rights vis-a-vis the rights of health professionals to opt out of providing the service on conscience grounds. Although scholars from various disciplines have addressed this issue in the literature, there is a lack of empirical research on the topic. This paper provides a documentary analysis of three examples of conscientious objection on religious grounds to performing abortion-related care by midwives in different Member States of the European Union, two of which have resulted in legal action. These examples show that as well as the laws of the respective countries and the European Union, professional and church law each played a part in the decisions made. However, support from both professional and religious sources was inconsistent both within and between the examples. The authors conclude that there is a need for clear guidelines at both local and pan-European level for health professionals and recommend a European-wide forum to develop and test them.

Professional and conscience-based refusals: the case of the psychiatrist's harmful prescription

By way of a case story, two common presuppositions in the academic debate on conscientious objection in healthcare are challenged. First, the debate typically presupposes a sharp division between conscience-based refusals based on personal core moral beliefs and refusals based on professional (eg, medical) reasons. Only the former might involve the moral gravity to warrant accommodation. The case story challenges this division, and it is argued that just as much might sometimes be at stake morally in refusals based on professional reasons. The objector's moral integrity might be equally threatened in objections based on professional reasons as in objections based on personal beliefs. Second, the literature on conscientious objection typically presupposes that conflicts of conscience pertain to well-circumscribed and typical situations which can be identified as controversial without attention to individualising features of the concrete situation. However, the case shows that conflicts of conscience can sometimes be more particular, born from concrete features of the actual situation, and difficult, if not impossible, to predict before they arise. Guidelines should be updated to address such 'situation-based' conscientious refusals explicitly.

Wrongness, Responsibility, and Conscientious Refusals in Health Care

In this article, I address what kinds of claims are of the right kind to ground conscientious refusals. Specifically, I investigate what conceptions of moral responsibility and moral wrongness can be permissibly presumed by conscientious objectors. I argue that we must permit HCPs to come to their own subjective conclusions about what they take to be morally wrong and what they take themselves to be morally responsible for. However, these subjective assessments of wrongness and responsibility must be constrained in several important ways: they cannot involve empirical falsehoods, objectionably discriminatory attitudes, or unreasonable normative beliefs. I argue that the sources of these constraints are the basic epistemic, relational, and normative competencies needed to function as a minimally decent health-care professional. Finally, I consider practical implications for my framework, and argue that it shows us that the objection raised by the plaintiffs in Zubik v. Burwell is of the wrong sort.

Objection to Conscience: An Argument Against Conscience Exemptions in Healthcare

I argue that appeals to conscience do not constitute reasons for granting healthcare professionals exemptions from providing services they consider immoral (e.g. abortion). My argument is based on a comparison between a type of objection that many people think should be granted, i.e. to abortion, and one that most people think should not be granted, i.e. to antibiotics. I argue that there is no principled reason in favour of conscientious objection qua conscientious that allows to treat these two cases differently. Therefore, I conclude that there is no principled reason for granting conscientious objection qua conscientious in healthcare. What matters for the purpose of justifying exemptions is not whether an objection is 'conscientious', but whether it is based on the principles and values informing the profession. I provide examples of acceptable forms of objection in healthcare.

The role of anticipated decision regret and the patient's best interest in sterilisation and medically assisted reproduction

There is a clear discrepancy in the way those who request medical assistance in pursuit of their reproductive choices are treated. On the one hand, women who request a sterilisation are urged to consider possible future regrets and are sometimes refused treatment in anticipation of such regrets. This is despite the fact that for all age ranges, the majority of women undergoing a sterilisation do not regret the decision. Moreover, women who are voluntarily childless are likely to have a happier and more gratifying life than parents. On the other hand, women who request fertility treatment are not urged to second guess their desire for parenthood. Although the fact that the probability of regret is expected to be higher in the former case than in the latter justifies this difference in treatment to a certain extent, the gap between the two different approaches is wider than it ought to be if we also take future well-being into consideration, instead of focussing exclusively on anticipated decision regret.

Autonomy, age and sterilisation requests

Sterilisation requests made by young, child-free adults are frequently denied by doctors, despite sterilisation being legally available to individuals over the age of 18. A commonly given reason for denied requests is that the patient will later regret their decision. In this paper, I examine whether the possibility of future regret is a good reason for denying a sterilisation request. I argue that it is not and hence that decision-competent adults who have no desire to have children should have their requests approved. It is a condition of being recognised as autonomous that a person ought to be permitted to make decisions that they might later regret, provided that their decision is justified at the time that it is made. There is also evidence to suggest that sterilisation requests made by men are more likely to be approved than requests made by women, even when age and number of children are factored in. This may indicate that attitudes towards sterilisation are influenced by gender discourses that define women in terms of reproduction and mothering. If this is the case, then it is unjustified and should be addressed. There is no good reason to judge people's sterilisation requests differently in virtue of their gender.