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Two Concepts of Conscience and their Implications for Conscience-Based Refusal in Healthcare

Published online by Cambridge University Press:  09 December 2016

STEVE CLARKE
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Abstract:

Healthcare professionals are not currently obliged to justify conscientious objections. As a consequence, there are currently no practical limits on the scope of conscience-based refusals in healthcare. Recently, a number of bioethicists, including Christopher Meyers, Robert D. Woods, Robert Card, Lori Kantymir, and Carolyn McLeod, have raised concerns about this situation and have offered proposals to place principled limits on the scope of conscience-based refusals in healthcare. Here, I seek to adjudicate among their proposals. I argue that to adjudicate among them properly it is important to consider the theoretical bases for conscientious objection. I further argue that there are two such bases to be considered. Some conscientious objections are justified by appeal to all-things-considered moral judgments, and some are justified by appeal to the “dictates of conscience.” I argue that both of these bases are legitimate and that both should be accommodated in any principled scheme to limit the scope of conscientious refusals in healthcare.

Keywords

all-things-considered judgmentconscienceconscience-based refusal in healthcareconscientious objectionintuition
Type
Special Section: Conscientious Objection in Healthcare: Problems and Perspectives
Information
Cambridge Quarterly of Healthcare Ethics , Volume 26 , Issue 1 , January 2017 , pp. 97 - 108
Copyright
Copyright © Cambridge University Press 2016 

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References

Notes

1. Wicclair reports that he was unable to find any academic articles published prior to the 1960s that specifically addressed the topic of conscientious objection in healthcare. Wicclair, M. Conscientious Objection in Health Care: An Ethical Analysis. Cambridge: Cambridge University Press; 2011:14.CrossRefGoogle Scholar

2. Cited by Wicclair 2011, at 16.

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9. See note 8, Meyers, Woods 1996, at 115. In Italy, approximately 70 percent of gynecologists conscientiously object to abortion. For discussion of the difficulties this situation creates for Italian women who wish to have an abortion, see Minerva, F. Conscientious objection in Italy. Journal of Medical Ethics 2015;41:170–3.

10. See note 8, Meyers, Woods 1996, at 117.

11. The United Kingdom is another place where healthcare workers are not required to provide a justification for conscientious refusals. See Cowley C. Conscientious objection and healthcare in the UK: Why tribunals are not the answer. Journal of Medical Ethics 2016;42:69–72.

12. See note 8, Meyers, Woods 1996, at 116–7.

13. Strickland, SLM. Conscientious objection in medical students: A questionnaire survey. Journal of Medical Ethics 2012;38:23.

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18. See note 8, Meyers, Woods 1996. Meyers and Woods discuss cases in which physicians have objected to conducting abortions on the grounds that abortion services are not lucrative and that second trimester abortions are “complex and frankly ugly,” at 118. Minerva mentions the case of a conscientious objector to abortion who was caught conducing abortions in his private practice: See note 9, Minerva 2015, at 172. Presumably his motives were financial.

19. See note 17, Meyers, Woods 2007, at 20.

20. See note 14, Kantymir, McLeod 2014, at 16.

21. See note 15, Card 2007 and Card 2011.

22. This line of criticism of Card is developed further in Marsh J. Conscientious refusals and reason-giving. Bioethics 2014;28(6):313–9. For a response and elaboration of the reason requirement, see Card R. Reasonability and conscientious objection in medicine: A reply to Marsh and an elaboration of the reason-giving requirement Bioethics 2014;28(6):320–6.

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25. See note 14, Kantymir, McLeod 2014.

26. Kantymir and Mcleod argue that if conscientious objectors opt for the latter course of action, they should be required to do slightly more than meet Meyers and Woods’ genuineness criterion. They should also be required to demonstrate that “patients will still get care the care they need in a respectful and timely fashion, any empirical beliefs on which the objection rests are not baseless, and the moral or religious beliefs on which it rests are not discriminatory” (See note 14, Kantymir, McLeod 2014, at 21). Discussion of whether or not these additional requirements are warranted is beyond the scope of this article.

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33. The cited text is from the abstract for Thagard, Finn 2015 (see note 31).

34. See note 31, Thagard, Finn 2015, at 150.

35. See note 8, Meyers, Woods 1996; see also note 17, Meyers, Woods 2007.

36. See note 31, Thagard, Finn 2015.

37. See note 32 Haidt 2012; see also Greene, J. Moral Tribes: Emotion, Reason and the Gap between Us and Them. New York: Penguin; 2014.Google Scholar

38. It is possible that there are some people who are psychologically unusual and who do not experience the powerful emotions that are usually associated with moral intuition. This may be the case for some severely autistic people. If such psychological unusualness can be demonstrated, then decisionmakers should be willing to make exceptions.

39. See note 15, Card 2007 and Card 2011; see also note 8, Meyers, Woods 1996 and note 17 Meyers, Woods, 2007.

40. See note 14, Kantymir, McLeod 2014.

41. Sulmasy D. What is conscience and why is respect for it so important? Theoretical Medicine and Bioethics 2008;29:137.

42. See note 32,Haidt 2001 and Haidt 2012.

43. See note 41, Sulmasy 2008.

44. See note 27, Sorabji 2014, at 170.

45. See, for example, Audi R. The Good in the Right: A Theory of Intuition and Intrinsic Value. Princeton: Princeton University Press; 2004; and Huemer M. Ethical Intuitionism. New York: Palgrave Macmillan; 2005.

46. See note 41, Sulmasy 2008. Sulmasy appears to accept that epistemic modesty is important. He discusses the topic under the broader heading of tolerance, and he is not wrong to do so. There is a tradition, going back to Pierre Bayle (see Bayle P [Tannenbaum AG, ed. and trans.] Philosophical Commentary. New York: Lang, 1685 [1987]) of grounding the value of tolerance of differences of opinion, especially differences of religious opinion, on the virtue of epistemic modesty.

47. Twain, M. The Adventures of Huckleberry Finn. London: Penguin Classics; 1884 [2012].CrossRefGoogle Scholar

48. See note 32, Haidt 2001 and Haidt 2012.