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.

HHS Issues Revised Health Worker Conscience Rule

The aim is to balance the rights of clinicians and patients.

Understanding the extent of and limitations to conscientious objection to abortion by health care practitioners: A hermeneutic study

The United Kingdom's Abortion Act 1967 has attracted substantial controversy, which has centred not only on the regulation of abortion itself, but also on the extent to which conscientious objection should be permitted. The aim of this study was to examine a range of healthcare professionals' views on conscientious objection and identify the appropriate parameters of conscientious objection to abortion. Gadamer's hermeneutic was utilised to frame this study. We conducted semi-structured interviews in two UK locations with 18 pharmacists, 17 midwives, 12 nurses and nine doctors, encompassing a mix of conscientious objectors and non-objectors to abortion. A multi-faceted in-depth data analysis led to the development of a hermeneutic of "respecting self and others". Four major themes of "doing the job", "entrusting to others", "acknowledging institutional power" and "being selective" and 18 subthemes contributed to this overarching theme. The complexity of the responses indicates that there is little consistency within and between each profession. They show that participants who were conscientious objectors were accepted by their colleagues and accommodated without detriment to the service, and that in larger hospitals, such as those where our work was carried out, it is possible to be employed in the service areas that include abortion while still being a conscientious objector. Finally, our results indicate that, by respecting of self and others, each profession should be able to accommodate conscience-based objections where individual practitioners seek to exercise them. Conscientious objectors as well as non-objectors have something to contribute to the ongoing development of the maternity and gynaecological services as abortion is only a small part of the work of these services.

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.

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.

Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women

We address the ethical and legal considerations for elective tubal sterilization in young, nulliparous women in Canada, with comparison with the United States and the United Kingdom. Professional guidelines recommend that age and parity should not be obstacles for receiving elective permanent contraception; however, many physicians hesitate to provide this procedure to young women because of the permanence of the procedure and the speculative possibility of regret. At the practice level, this means that there are barriers for young women to access elective sterilization; they are questioned or not taken seriously, or their desire for sterilization is more generally belittled by health care professionals. This article argues for further consideration of these requests and considers the ethical and legal issues that arise when preventing regret is prioritized over autonomy in medical practice. In Canada, there is a paucity of professional guidelines and articles offering practical considerations for handling such requests. Compared with the U.S. and U.K. policy contexts, we propose a patient-centered approach for practice to address requests for tubal sterilization that prioritizes informed consent and respect for patient autonomy. We ultimately aim to assure physicians that when the conditions of informed consent are met and documented, they practice within the limits of the law and in line with best ethical practice by respecting their patients' choice of contraceptive interventions and by ensuring their access to care.

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.

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.

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.

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.

Liberty to Request Exemption as Right to Conscientious Objection

There is a regulatory option for conscientious objection in health care that has yet to be systematically examined by ethicists and policymakers: granting a liberty to request exemption from prescribed work tasks without a companion guarantee that the request is accommodated. For the right-holder, the liberty's value lies in the ability to seek exemption without duty-violation and a tangible prospect of reassignment. Arguing that such a liberty is too unreliable to qualify as a right to conscientious objection leads to the problem of consistently distinguishing its effects from those of a right to conscientious objection that is made conditional on an individual assessment of the objector's motivation. These properties require that we distinguish the liberty to request exemption from more restrictive policy choices, and that we subject it to greater scrutiny in the wider moral discourse as a possible variant of a right to conscientious objection.

Conscientious Objection in Australia: A Comparison between Abortion and Voluntary Assisted Dying

Abortion and voluntary assisted dying (VAD) are areas of health care that elicit passionate and emotional responses. As a result of the diverse perspectives relating to these forms of medical care, Australian law allows for conscientious objection in both contexts. This article considers the role of conscientious objection in health care in Australia, with a particular focus on abortion and VAD. In begins by considering the legal position, highlighting some of the key differences in the way that conscientious objection is regulated in these two contexts and between Australian jurisdictions. It observes that jurisdictions which have legalised both abortion and VAD have not necessarily adopted the same approach to the question of conscientious objection as it pertains to abortion versus VAD. The article then turns to consider the reality of conscientious objection "on the ground" across these two domains in an effort to understand this distinction.

Voluntary Assisted Dying Act 2021 (Qld): Conscientious Objection Controversies

The right to conscientious objection has been reflected in multiple Australian jurisdictions for different purposes. The Voluntary Assisted Dying Act 2021(Qld) provides for conscientious objection and the scope of these provisions has proved a contentious topic. Through applying casuistical approaches and a rights-based ethical perspective, this article seeks to determine whether the referral requirement for objecting practitioners appropriately infringes on a practitioner's right of conscientious objection; whether the scope of professionals eligible to object conscientiously has been appropriately formulated; and whether an obligation to refer without a penalty for failure is a sufficient patient safeguard. The discussion concludes with possible considerations for future amendments to the Voluntary Assisted Dying Act.

Why the Post-Roe Era Requires Protecting Conscientious Provision as We Protect Conscientious Refusal in Health Care

The US Supreme Court overturned Roe v Wade in June 2022, and now each state's legislature will decide if and when its citizens will have legal access to abortion care and if and when its physicians will be criminalized for providing what is considered to be the standard of care by multiple health-related organizations. This extraordinary change in the medico-legal landscape requires reevaluation of health profession codes of ethics related to clinician conscience. This article argues that these codes must now be expanded to address 2 newly critical areas: physician advocacy to make abortion illegal and affirmative protection for "conscientious provision" in hostile environments on par with protection of conscientious refusal.

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.

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.

The Reasonableness Standard for Conscientious Objection in Healthcare

In complex, pluralistic societies, different views concerning the moral duties of healthcare professionals inevitably exist: according to some accounts, doctors can and should cooperate in performing abortion or physician-assisted suicide, while according to others they should always defend human life and protect their patients' health. It is argued that the very plurality of responses presently given to questions such as these provides a liberal argument in favour of conscientious objection (CO), as an attempt to deal with moral diversity by protecting both the professionals' claim to moral integrity and the patients' claim to receive lawful and safe medical treatments. A moderate view on CO is defended, according to which none of these claims can be credited with unconditional value. Claims to CO by healthcare professionals can be justified but must be subjected to a reasonableness standard. Both the incompatibility of CO with the medical profession and its unconditional sanctioning by conscience absolutism are therefore rejected. The paper contributes to the definition of the conditions of such reasonableness, particularly by stressing the role played by conceptions of good medicine in discriminating claims to CO; it is argued that respecting these conditions prevents from having the negative consequences dreaded by critics. The objection according to which accepting the physician's duty to inform and refer is inconsistent with the professed value of moral integrity is also discussed.

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.

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.

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.

"I haven't had to bare my soul but now I kind of have to": describing how voluntary assisted dying conscientious objectors anticipated approaching conversations with patients in Victoria, Australia

BACKGROUND

Dealing with end of life is challenging for patients and health professionals alike. The situation becomes even more challenging when a patient requests a legally permitted medical service that a health professional is unable to provide due to a conflict of conscience. Such a scenario arises when Victorian health professionals, with a conscientious objection (CO) to voluntary assisted dying (VAD), are presented with patients who request VAD or merely ask about VAD. The Voluntary Assisted Dying Act 2017 (Vic) recognizes the inherent conflict of conscience that may arise for some health professionals when asked to provide VAD and responds by affording broad protection to conscientious objectors who wish to refuse to take part in the VAD process.

METHODS

Seventeen semi-structured qualitative interviews were conducted with Victorian health professionals with a self-identified CO to VAD in the lead-up to the implementation of VAD in Victoria. Interviews explored how participants anticipated they would manage their CO in practice. Interviews were transcribed verbatim and analyzed thematically.

RESULTS

Our results reveal that the way in which health professionals claimed they would approach CO conversations is variable and was dependant on the strength of their opposition to VAD. We categorized conscientious objectors according to their approach as either dissuasive non-referrers, passive non-referrers, facilitators or negotiators. Our study also explores the perceived difficulties of exercising one's CO as identified by our participants.

CONCLUSION

The broad protection offered by the Voluntary Assisted Dying Act 2017 (Vic) encourages a range of behaviors from conscientious objectors, due to the minimal obligations imposed. In order to assist conscientious objectors, more policy, institutional guidance, and education needs to be available to conscientious objectors explicitly addressing how to effectively manage one's CO. Such guidance is imperative to ensuring that their moral integrity is preserved and that they are exercising their CO appropriately.

Unjustified Asymmetry: Positive Claims of Conscience and Heartbeat Bills

In 2019, several US states passed "heartbeat" bills. Should such bills go into effect, they would outlaw abortion once an embryonic heartbeat can be detected, thereby severely limiting an individual's access to abortion. Many states allow health care professionals to refuse to provide an abortion for reasons of conscience. Yet heartbeat bills do not include a positive conscience clause that would allow health care professionals to provide an abortion for reasons of conscience. I argue that this asymmetry is unjustified. The same criteria that justify protecting conscientious refusals to provide abortion also justify protecting positive conscientious appeals regarding abortion. Thus, if the law provides legal exemptions for health care professionals who, as a matter of conscience, refuse to provide abortions where it is legal, it should also provide exemptions for health care professionals who, as a matter of conscience, feel obligated to provide abortions where it is illegal.

In Defence of Forgetting Evil: A Reply to Pilkington on Conscientious Objection

In a recent article for this journal, Bryan Pilkington (2019) makes a number of critical observations about one of our arguments for non-traditional medical conscientious objectors' duty to refer. Non-traditional conscientious objectors are those professionals who object to indirectly performing actions-like, say, referring to a physician who will perform an abortion. In our response here, we discuss his central objection and clarify our position on the role of value conflicts in non-traditional conscientious objection.

Reply to: Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests

Giubilini and Savulescu in their recent Journal of Bioethical Inquiry symposium article presented an account of conscientious objection that argues for its recognition as a non-financial conflict of interest. In this short commentary, I highlight some problems with their account. First, I discuss their solicitor analogy. Second, I discuss some problems surrounding their objectivity claim about standards of medical care. Next, I discuss some issues arising from consistently applying their approach. Finally, I highlight that conscientious objection should be viewed not as a conflict of interest but as something that society has an interest in preserving. I conclude by arguing that clinicians who have a conscientious objection can be treated in the same way as those who decide to subspecialize and do not need to give up work in their specialty. While Giubilini and Savulescu present an interesting argument about conscientious objection, theirs is not a compelling view. Indeed, the way we approach conscientious objection has more to teach us about conflicts of interest than the other way around.

Conscientious Objection, Conflicts of Interests, and Choosing the Right Analogies. A Reply to Pruski

In this response paper, we respond to the criticisms that Michal Pruski raised against our article "Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests." We defend our original position against conscientious objection in healthcare by suggesting that the analogies Pruski uses to criticize our paper miss the relevant point and that some of the analogies he uses and the implications he draws are misplaced.

Doctors during the COVID-19 pandemic: what are their duties and what is owed to them?

Doctors form an essential part of an effective response to the COVID-19 pandemic. We argue they have a duty to participate in pandemic response due to their special skills, but these skills vary between different doctors, and their duties are constrained by other competing rights. We conclude that while doctors should be encouraged to meet the demand for medical aid in the pandemic, those who make the sacrifices and increased efforts are owed reciprocal obligations in return. When reciprocal obligations are not met, doctors are further justified in opting out of specific tasks, as long as this is proportionate to the unmet obligation.

The overprotection of conscientious objection in Chile's abortion regulation

This paper critically analyses conscientious objection to abortion in the context of the new regulation of pregnancy termination in Chile. It argues that adequate regulation should not be blind: The bioethical requirements that seek to balance the interests involved must consider the legal regulation of the interests at stake, the context in which they are implemented, and, fundamentally, the effectiveness of the solutions adopted. Attention should be paid to the risks involved in the political use of conscientious objection to prevent the implementation of women's reproductive rights. In describing the process of the entrenchment and expansion of conscientious objection to abortion in Chile, we show how this process has overprotected conscience and how the risks of undermining the effectiveness of the new abortion legislation hinder the enjoyment of rights entrenched by the law.

Impact of a contactless prescription pickup kiosk on prescription abandonment, patient experience, and pharmacist consultations

OBJECTIVE

Investigate the impact of increased access to new and refilled prescriptions by means of an automated pickup kiosk (Asteres ScriptCenter) on prescription abandonment rates, patient experience, and pharmacist consultations.

DESIGN

Nonrandomized, observational study using retrospective, deidentified data from the filling pharmacy, the kiosk, and a pharmacist-completed counseling documentation log over a 35-month study period.

SETTING AND PARTICIPANTS

Hospital employees opting to use a kiosk located in the lobby with 24 hours a day, 7 days a week access for pickups and a telephone pharmacist consultation service compared with employees using the regular counter at the filling pharmacy.

OUTCOME MEASURES

Return to stock (RTS) rate to assess prescription abandonment, time to prescription pickup, consultation duration, kiosk user assessment, and pharmacist assessment of counseling ability.

RESULTS

Approximately 9% of employees (440) enrolled to use the kiosk, with 5062 kiosk pickups recorded for new prescriptions (29%), refill prescriptions (33%), and over-the-counters (38%). The mean kiosk RTS (4.3% ± 3.2) was lower than that at the regular counter (5.6% ± 0.8), P = 0.04, whereas the mean time to pickup was approximately 1 day greater at the kiosk than the regular counter (2.8 ± 0.4 vs. 1.8 ± 0.2, P < 0.001). The average kiosk consultation was approximately 1 minute shorter (2.0 ± 1.4) than that of the regular counter (3.4 ± 1.9, P < 0.001), and fewer patients using the kiosk (15.7%) had additional questions at the end of a consultation session than patients at the regular counter (38.8%, P < 0.001). Most of the kiosk users agreed that their prescription questions were answered and that kiosk convenience was an important reason for using the filling pharmacy. Almost all (>90%) pharmacists indicated that they were able to effectively counsel patients at the kiosk and the regular counter.

CONCLUSION

The kiosk, used by self-selected health care workers located in a hospital workplace setting with 24 hours a day, 7 days a week access, was a convenient, contactless pickup extension of the filling pharmacy with a lower prescription abandonment rate and similar pickup and consultation characteristics as at the regular pharmacy counter.

Professionals' experience with conscientious objection to abortion in Addis Ababa, Ethiopia: An interview study

In Ethiopia, conscientious objection (CO) to abortion provision is not allowed due to government regulations. We here report findings from a qualitative interview study of 30 healthcare professionals from different professions working with abortion in Addis Ababa, Ethiopia. CO is practised despite the regulations forbidding it. Most informants appeared to be unfamiliar with the prohibition or else did not accord it weight in their moral reasoning. Proponents of institutionalization/toleration of CO claimed that accommodation was often feasible in a hospital setting because colleagues could take over. Opponents pointed to threats to patient access in rural settings especially. Both proponents and opponents invoked tenets of professional ethics, viz., the right not to be coerced into actions one deems unacceptable, or the duty to provide care, respectively. More societal and professional discussion of the ethics and regulation of CO, and a clearer link between legal regulation and ethical guidance for professionals, are called for.

Should professional interpreters be able to conscientiously object in healthcare settings?

In a globalised world, healthcare professionals will inevitably find themselves caring for patients whose first language differs from their own. Drawing on experiences in Australia, this paper examines a specific problem that can arise in medical consultations using professional interpreters: whether the moral objections of interpreters should be accommodated as conscientious objections if and when their services are required in contexts where healthcare professionals have such entitlements, most notably in relation to consultations concerning termination of pregnancy and voluntary assisted dying. We argue that existing statements of professional ethics suggest that interpreters should not be accorded such rights. The social organisation of healthcare and interpreting services in Australia may mean those who have serious objections to particular medical practices could provide their services in restricted healthcare contexts. Nevertheless, as a general rule, interpreters who have such objections should avoid working within healthcare.

Conscientious objection in medicine: Experience in Chile

Latin American countries have slowly enacted laws decriminalizing abortion in three circumstances: Life-threatening risk for the pregnant woman, extra-uterine non-viability of malformed foetus, and pregnancy due to rape or incest. Chile is one of the last countries to adopt such a law, formulated in an increasingly restrictive format. Conservative politicians and Church-related healthcare institutions promptly announced individual and institutional conscientious objection based on the right of private facilities to obey their ideology and personal moral integrity. Juridical consultations and Constitutional Court rulings allowed private hospitals to uphold their objection even if contracted to provide some public health services. Under these conditions, only a few hundred women requested and obtained a legal abortion, while an estimated 100,000 continued to depend on unsafe procedures. Bioethical debate was silenced by the unfettered drive for conscientious objection that continues to limit women's autonomy, and fails to ease the public health scourge of massive unsafe clandestine abortions.

Exploring Eating and Nutritional Challenges for Children with Autism Spectrum Disorder: Parents' and Special Educators' Perceptions

Autism spectrum disorder (ASD) is a complex neurodevelopmental disability that is frequently associated with food refusal, limited food repertoire and high-frequency single food intake mainly among children with ASD. Provision of nutrition can be very challenging due to the fact of these behavioural problems, either for the parents or special educators. Healthy nutrition is associated with providing and consuming nutritious food with results being in a good state of health. Semi-structured focus group discussions (FGDs) were conducted among 20 participants at a National Autism Centre to explore their understanding towards healthy nutrition. They were parents and special educators who were actively involved with children with ASD. A series of discussions were transcribed verbatim, and four researchers examined each transcript. Inductive analysis linking codes into main thematic categories was conducted using the constant comparison approach across the full data set. The outcome suggested that participants had limited knowledge relating to the proper dietary and nutritional needs of the children. The key messages from the discussion provide a foundation on the development of a nutrition education module which involves primary caretakers of children with ASD.

Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests

Conflict of interests (COIs) in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner's financial interest conflicts with patients' interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of "interests" cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners' moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs.

Medical and midwifery students' views on the use of conscientious objection in abortion care, following legal reform in Chile: a cross-sectional study

BACKGROUND

In August 2017, Chile lifted its complete ban on abortion by permitting abortion in three limited circumstances: 1) to save a woman's life, 2) lethal fetal anomaly, and 3) rape. The new law allows regulated use of conscientious objection (CO) in abortion care, including allowing institutions to register as objectors. This study assesses medical and midwifery students' support for CO, following legal reform.

METHODS

From October 2017 to May 2018, we surveyed medical and midwifery students from seven universities located in Santiago, Chile. Universities included 4 secular (2 public and 2 private) and 3 private religiously-affiliated universities; all offering medical degrees with a specialization in obstetrics and gynecology (ob-gyn) and five offering midwifery degrees. We used generalized estimating equations (GEE) to identify characteristics associated with student support for CO, intentions to use CO to refuse to care for someone seeking abortion, and support for CO at the institutional level.

RESULTS

333 of the 413 eligible students who opened the survey, completed the questions on conscientious objection; 26% were seeking medical degrees with an ob-gyn specialty, 25% were seeking midwifery degrees, and 49% were seeking medical degrees and had not yet decided their specialty. While nearly all endorse requirements for conscientious objecting clinicians to inform (92%) and refer (91%) abortion-seeking patients, a minority (18%) would personally use conscientious objection to avoid caring for a patient seeking abortion (12% secular and 39% religious university students). About half of religious-university students (52%) and one-fifth of secular-university (20%) students support objections at the institutional level.

CONCLUSIONS

Most students support the regulated use of CO which preserves patients' access to abortion care. Religious-university student views on the use of conscientious objection in abortion care are discordant with those of their institutions which currently support institutional-level objections.

Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice.

[Refusal of care, a discriminatory act?]

If a patient can refuse care, health professionals may refuse to treat a person, an act often considered discriminatory. Investigations have been carried out to shed light on this practice. This notion calls for a philosophical and ethical point of view.

Positive or Negative? Consistency and Inconsistency in Claims of Conscience

The debate about positive and negative claims of conscience is, in large part, about ethical consistency. In this commentary I argue that there can be differences between conscientious provision of treatment and conscientious nonprovision of treatment that are ethically relevant. However, in many cases, including those described in this commentary, there is not sufficient ethical reason to treat them differently. This means that asymmetrical conscientious objection policies are potentially unjustified.

Should Positive Claims of Conscience Receive the Same Protection as Negative Claims of Conscience? Clarifying the Asymmetry Debate

In the debate over clinicians' conscience, there is a greater ethical, legal, and scholarly focus on negative, rather than positive, claims of conscience. This asymmetry produces a seemingly unjustified double standard with respect to clinicians' conscience under the law. For example, a Roman Catholic physician working at a secular institution may refuse to provide physician-aid-in-dying on the basis of conscience, but a secular physician working at a Roman Catholic institution may not insist on providing physician-aid-in-dying on the basis of conscience. This article outlines arguments against this asymmetry and critiques them for failing to distinguish between positive claims of conscience as positive or negative rights. I suggest the asymmetry debate should be focused on whether positive claims of conscience as positive rights ought to enjoy the same protections as negative claims of conscience. Clarifying the debate in this way helps elucidate some of the best reasons for the asymmetry, which these arguments have not addressed. This article does not take a definitive position on whether the asymmetry is justified, but attempts to bring some focus to the debate by directing arguments against the asymmetry to address the significant differences between positive claims of conscience as positive rights and negative claims of conscience.

Remember Evil: Remaining Assumptions In Autonomy-based Accounts Of Conscience Protection

Discussions of the proper role of conscience and practitioner judgement within medicine have increased of late, and with good reason. The cost of allowing practitioners the space to exercise their best judgement and act according to their conscience is significant. Misuse of such protections carve out societal space in which abuse, discrimination, abandonment of patients, and simple malpractice might occur. These concerns are offered amid a backdrop of increased societal polarization and are about a profession (or set of professions) which has historically fought for such privileged space. There is a great deal that has been and might yet be said about these topics, but in this paper I aim to address one recent thread of this discussion: justification of conscience protection rooted in autonomy. In particular, I respond to an argument from Greenblum and Kasperbaur (2018) and clarify a critique I offered (2016) of an autonomy-based conscience protection argument which Greenblum and Kasperbaur seek to improve and defend. To this end, I briefly recap the central contention of that argument, briefly describe Greenblum and Kasperbaur's analysis of autonomy and of my critique, and correct what appears to be a mistake in interpretation of both my work and of autonomy-based defenses of conscience protection in general.

Nazis, Teleology, and the Freedom of Conscience: In Response to Gamble and Pruski's 'Medical Acts and Conscientious Objection: What Can a Physician be Compelled to Do?'

Medical practitioners of all specialisms (e.g. RN, MD) are identified by their professional titles. Their function is determined by their regulators, and subject to voluntary employment contracts. Whilst they are expected to act in their patients' best interests, there are situations in which a physician - having human rights - can object to certain acts. This right of objetction arises from the recognition of the practitioner's own conscience rather than the end or purpose of the procedure being performed. Gamble and Pruski explore an act-centred morality, and therefore define acts as medical (and subject to compulsion) and non-medical (therefore voluntary). This analysis has merit when applied to health-systems as a whole, but fails to take into account the humanity of physicians and the specific interactions with patients in different contexts. As such, it serves as a way of compelling physicians to act against their conscience rather than protecting them.

Refused and referred-persistent stigma and discrimination against people living with HIV/AIDS in Bihar: a qualitative study from India

OBJECTIVES

This study aimed to explore barriers to accessing care, if any, among people living with HIV/AIDS (PLHA) in two districts of Bihar. We also aimed to assess attitudes towards PLHA among healthcare providers and community members.

DESIGN

This qualitative study used an exploratory study design through thematic analysis of semistructured, in-depth interviews.

SETTING

Two districts were purposively selected for the study, namely the capital Patna and a peripheral district located approximately 100 km from Patna, in order to glean insights from a diverse sample of respondents.

PARTICIPANTS

Our team purposively selected 71 participants, including 35 PLHA, 10 community members and 26 healthcare providers.

RESULTS

The overarching theme that evolved from these data through thematic coding identified that enacted stigma and discrimination interfere with each step in the HIV care continuum for PLHA in Bihar, India, especially outside urban areas. The five themes that contributed to these results include: perception of HIV as a dirty illness at the community level; non-consensual disclosure of HIV status; reliance on identifying PLHA to guide procedures and resistance to universal precautions; refusal to treat identified PLHA and referrals to other health centres for treatment; and inadequate knowledge and fear among health providers with respect to HIV transmission.

CONCLUSIONS

The continued presence of discriminatory and stigmatising attitudes towards PLHA negatively impacts both disclosure of HIV status as well as access to care and treatment. We recognise a pressing need to improve the knowledge of HIV transmission, and implement universal precautions across all health facilities in the state, not just to reduce stigma and discrimination but also to ensure proper infection control. In order to improve treatment adherence and encourage optimal utilisation of services, it is imperative that the health system invest more in stigma reduction in Bihar and move beyond more ineffective, punitive approaches.

[Elderly patients in the ICU: extending life to the max?]

With an ageing population, the number of very old patients that are admitted to an intensive care unit (ICU) is also increasing. The possible benefit of ICU admission for these patients should be weighed against the risks of cognitive and functional impairment. Prospective studies are necessary to optimize the triage process and to identify factors, other than age, that are related to long-term outcome in ICU patients.