Medical students' attitudes towards conscientious objection: a survey

Attitudes of undergraduate medical students towards end-of-life decisions: a systematic review of influencing factors

BACKGROUND

Medical end-of-life decisions, including voluntary active euthanasia (lethal injection), (physician-)assisted dying (prescribing lethal substances), passive euthanasia (refraining from or ceasing life-sustaining treatments), palliative sedation (administering sedatives to alleviate suffering, possibly leading to unintended life-shortening), and treatment withdrawal/withholding, have become prevalent in modern medical practice.

AIM

This systematic review aims to analyse international data on undergraduate medical students' attitudes towards (physician-) assisted dying, palliative sedation, treatment withdrawal/withholding, active and passive euthanasia. The objectives are to assess approval rates over the past 24 years and to identify factors influencing these attitudes.

DESIGN

In accordance with PRISMA guidelines, a systematic search of six electronic databases (MEDLINE, CINAHL, EMBASE, ERIC, PsycINFO, and Web of Science) was conducted. The review encompasses studies from 2000-2024.

RESULTS

Forty-nine studies met the inclusion criteria (43 surveys, 6 qualitative studies, 1 mixed-method study). The studies were globally distributed: Europe (27), Asia (10), America (8), Africa (3), and Australia (1). Predictors such as age, clinical vs. pre-clinical status, religious aspects, sex, and ethnicity were investigated. Age and gender had limited influence, whereas religion was a significant factor. Compared with pre-clinical students, clinical students showed more support for end-of-life practices. Geographic locations and socioeconomic status also affect attitudes.

CONCLUSION

Medical students' attitudes towards end-of-life decisions are influenced by clinical experience, religious beliefs, and geographic location. The acceptance rates for euthanasia and (physician-)assisted dying vary significantly across regions, reflecting diverse cultural and educational backgrounds.

What do medical students think about conscientious objection? A cross-sectional study from Turkey

BACKGROUND

Physicians' refusal to perform medical procedures that they deem contrary to their conscience may threaten basic human rights and public health. This study aims to investigate the thoughts and attitudes of future physicians on conscientious objection (CO) and thus contribute to the discussions from a country more heavily influenced by Eastern values.

METHODS

A cross-sectional multi-center study was conducted among medical students country-wide, where 2,188 medical students participated via an online survey. The methodology was in accordance with the CHERRIES.

RESULTS

Nearly half of the students think that CO should be a right. If a medical intervention that conflicts with their personal values is requested, two-thirds would request an assignment to take another action if possible, and 8.2% stated that they would refuse to participate at all costs. If CO is recognized as a right, one-third of the participants would not refer the patient. Male participants, the ones who are more religious, and who have chosen medicine for pragmatic reasons, were more supportive of the right to refuse medical interventions that may contradict their moral values, culture, or beliefs (p = 0.000, 0.000, 0.021, respectively). Also, students who thought that conscience is a voice within us that has existed since we were born and who believed everyone must pay for all healthcare services were statistically more likely to agree that CO should be a right (p = 0.000, 0.008, respectively). The participants stated that they would most frequently object to requests for extreme aesthetic interventions (splitting the tongue in half - 39.1%, changing eye color - 28.2%, removing the lowest rib - 26.8%), euthanasia (23.2%), hymen restoration (17.3%), gender change (16.5%), and optional pregnancy termination (14.0%).

CONCLUSIONS

Developing undergraduate and post-graduate education that integrates CO as a specific topic, clarifying the conceptual definitions, and improving/developing protocols for exercising CO seem crucial to prevent possible violations of rights and to protect health professionals' integrity. These interventions should be carried out with the participation of all parties to come together in open communication and respectful dialogue in this delicate matter.

Conscientious objection - a cross-sectional, vignette-based, mixed methods exploration of Australian pharmacists' perspectives

Background: Conscientious objection (CO) in healthcare is a controversial topic. Some perceive CO as freedom of conscience, others believe their professional duty-of-care overrides personal-perspectives. There is a paucity of literature pertaining to pharmacists' perspectives on CO. Aim: To explore Australian pharmacists' decision-making in complex scenarios around CO and reasons for their choices. Method: A cross-sectional, qualitative questionnaire of pharmacists' perspectives on CO. Vignette-based questions were about scenarios related to medical termination, emergency contraception, IVF surrogacy for a same-sex couple and Voluntary Assisted Dying (VAD) Results: Approximately half of participants (n = 223) believed pharmacists have the right to CO and most agreed to supply prescriptions across all vignettes. However, those who chose not to supply (n = 20.9%), believed it justifiable, even at the risk of patients failing to access treatment. Strong self-reported religiosity had a statistically significant relationship with decisions not to supply for 3 of 4 vignettes. Three emergent themes included: ethical considerations, the role of the pharmacist and training and guidance. Conclusion: This exploratory study revealed perspectives of Australian pharmacists about a lack of guidance around CO in pharmacy. Findings highlighted the need for future research to investigate and develop further training and professional frameworks articulating steps to guide pharmacists around CO.

The Association Between Religion and Healthcare Professionals' Attitudes Towards the Conscience Clause. A Preliminary Study From Poland

Objectives: This study was designed to determine the relationship between religion and healthcare practitioners' attitudes towards conscience clauses in Poland. Methods: We developed a survey assessing impact of religion on attitudes healthcare professionals towards the conscience clause. These questions were explored using a sample of 300 Polish healthcare professionals. Results: The results indicate that religiosity was a significant predictor of acceptance of conscience clauses. It also influenced healthcare practitioners' opinions on medical professionals that should be granted the right to conscience clauses and medical services that may be denied on moral grounds. There was also a significant relationship between healthcare practitioners' religiosity and their eagerness to use conscience clauses in a situation of moral conflict. Finally, religious healthcare practitioners were more concerned about the personal consequences of using this right in a medical environment. Conclusion: This study shows that at the same time, both religious and non-religious healthcare professionals believed that the Polish regulations regarding conscience clause are unclear and inaccurate, therefore leading to misinterpretation and abuse regulation of law.

Conscientious Objection and Other Motivations for Refusal to Treat in Hastened Death: A Systematic Review

BACKGROUND

Conscientious objection (CO) in the context of health care arises when a health care professional (HCP) refuses to participate in a certain procedure because it is not compatible with their ethical or moral principles. Refusal to treat in health care includes, in addition to CO, other factors that may lead the HCP not to want to participate in a certain procedure. Therefore, we can say that CO is a form of refusal of treatment based on conscience. Hastened death has become an increasingly reality around the world, being a procedure in which not all HCPs are willing to participate. There are several factors that can condition the HCPs' refusal to treat in this scenario.

METHODS

With the aim of identifying these factors, we performed a systematic review, following the PRISMA guidelines. On 1 October 2022, we searched for relevant articles on Pubmed, Web of Science and Scopus databases.

RESULTS

From an initial search of 693 articles, 12 were included in the final analysis. Several motivations that condition refusal to treat were identified, including legal, technical, social, and CO. Three main motivations for CO were also identified, namely religious, moral/secular, and emotional/psychological motivations.

CONCLUSIONS

We must adopt an understanding approach respecting the position of each HCP, avoiding judgmental and discriminatory positions, although we must ensure also that patients have access to care. The identification of these motivations may permit solutions that, while protecting the HCPS' position, may also mitigate potential problems concerning patients' access to this type of procedure.

Quotas: Enabling Conscientious Objection to Coexist with Abortion Access

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise—a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.

An ethical issue: nurses' conscientious objection regarding induced abortion in South Korea

Background

The Constitutional Court of South Korea declared that an abortion ban was unconstitutional on April 11, 2019. The National Health Care System will provide abortion care across the country as a formal medical service. Conscientious objection is an issue raised during the construction of legal reforms.

Methods

One hundred sixty-seven perioperative nurses responded to the survey questionnaire. Nurses’ perception about conscientious objection, support of legislation regarding conscientious objection, and intention to object were measured. Logistic regression was used to explore the factors associated with support of the legislation and the intention to conscientiously object.

Results

Only 28.8% of the responding nurses were aware of health care professionals’ conscientious objection. The majority (68.7%) felt that patients’ rights should be prioritized over health care professionals’ conscientious objection. On the other hand, 45.8% supported the legislation on conscientious objection to abortion, and 42.5% indicated a willingness to refuse to participate in an abortion case if conscientious objection was permitted. Religion, awareness of conscientious objection, and prioritizing of nurses’ right to conscientious objection were significantly associated with supporting the legislation. Moreover, religion and prioritizing nurses' rights were significantly associated with the intention to conscientiously object.

Conclusions

This study provides information necessary for further discussion of nurses’ conscientious objection. Nursing leaders, researchers, and educators should appeal to nurses and involve them in making policies that balance a women's right to non-discrimination and to receiving appropriate care with nurses' rights to maintain their moral integrity without compromising their professional obligation.

The inequity of conscientious objection: Refusal of emergency contraception

In the medical field, conscientious objection is claimed by providers and pharmacists in an attempt to forgo administering select forms of sexual and reproductive healthcare services because they state it goes against their moral integrity. Such claim of conscientious objection may include refusing to administer emergency contraception to an individual with a medical need that is time-sensitive. Conscientious objection is first defined, and then a historical context is provided on the medical field's involvement with the issue. An explanation of emergency contraception's physiological effects is provided along with historical context of the use on emergency contraception in terms of United States Law. A comparison is given between the United States and other developed countries in regard to conscientious objection. Once an understanding of conscientious objection and emergency contraception is presented, arguments supporting and contradicting the claim are described. Opinions supporting conscientious objection include the support of moral integrity, religious diversity, and less regulation on government involvement in state law will be offered. Finally, arguments against the effects of conscientious objection with emergency contraception are explained in terms of financial implications and other repercussions for people in lower socioeconomic status groups, especially people of color. Although every clinician has the right and responsibility to treat according to their sense of responsibility or conscience, the ethical consequences of living by one's conscience are limiting and negatively impact underprivileged groups of people. It is the aim of this article to advocate against the use of provider's and pharmacist's right to claim conscientious objection due to the inequitable impact the practice has on people of color and individuals with lower incomes.

[Conscientious objectors in Chilean medical education]

The Chilean Law regulating the voluntary interruption of pregnancy, contemplates the possibility that health personnel may refrain from doing the procedure if they have stated that they are conscientious objectors (CO). There are numerous articles on the subject. However, the impact on medical training centers when a student or resident abstain from performing certain clinical procedures invoking CO, has seldom been analyzed. In this article, we explore the rights and duties of the CO students to perform an abortion or other clinical procedures for either religious or cultural reasons. Based on international experience, we recommend that all health care centers should have established and publicly known policies on this matter. Finally, we honor CO invoked by students, based on three general principles. First, the autonomy and moral integrity of the students should be respected. Second, an adequate ethical sensitivity is promoted. Third, it contributes to the necessary heterogeneity and diversity of students, promoting a desirable pluralism. However, certain interests and values, such as the well-being of patients, must be considered over and above accepting the CO requests.

Secularity, abortion, assisted dying and the future of conscientious objection: modelling the relationship between attitudes

Background

Controversies arise over abortion, assisted dying and conscientious objection (CO) in healthcare. The purpose of the study was to examine the relationship between attitudes towards these bioethical dilemmas, and secularity and religiosity.

Method

Data were drawn from a 2017 web-based survey of a representative sample of 1615 Norwegian adults. Latent moderated structural equations modelling was used to develop a model of the relationship between attitudes.

Results

The resulting model indicates that support for abortion rights is associated with pro-secular attitudes and is a main “driver” for support for assisted dying and opposition to conscientious objection.

Conclusions

This finding should be regarded as a hypothesis which ought to be tested in other populations. If the relationship is robust and reproduced elsewhere, there are important consequences for CO advocates who would then have an interest in disentangling the debate about CO from abortion; and for health systems who ought to consider carefully how a sound policy on CO can safeguard both patient trust in the services and the moral integrity of professionals. It is suggested that if religiosity wanes and pro-secular and pro-abortion attitudes become more widespread, support for CO might decline, putting into question whether present policies of toleration of conscientious refusals will remain acceptable to the majority.

Opinions of nurses regarding conscientious objection

BACKGROUND

In the last decades, there have been important developments in the scientific and technological areas of healthcare. On certain occasions this provokes conflict between the patients' rights and the values of healthcare professionals which brings about, within this clinical relationship, the problem of conscientious objection.

AIMS

To learn the opinions that the Nurses of the Madrid Autonomous Community have regarding conscientious objection.

RESEARCH DESIGN

Cross-cutting descriptive study.

PARTICIPANTS AND RESEARCH CONTEXT

The nurses of 9 hospitals and 12 Health Centers in the Madrid Autonomous Community. The study was done by means of an auto completed anonymous questionnaire. The variables studied were social-demographical and their opinions about conscientious objections.

ETHICAL CONSIDERATIONS

The study was approved by the Ethical Community of Clinical Research of the University Hospital Príncipe de Asturias. Participants were assured of maximum confidentiality and anonymity.

FINDINGS

A total of 421 nurses answered the questionnaire. In total, 55.6% of the nurses confirmed they were religious believers, and 64.3% declared having poor knowledge regarding conscientious objection. The matters that caused the greatest objections were voluntary abortions, genetic embryo selection, refusal of blood transfusions, and therapy refusal.

DISCUSSION

Different authors state that the most significant cases of conscientious objections for health professionals are those regarding carrying out or assisting in abortions, euthanasia, the practice of assisted reproduction and, finally, the prescription and dispensing of the morning-after pill. In our study, the most significant cases in which the nurses would declare conscientious objections would be the refusal to accept treatment, the selection of embryos after genetic diagnosis preimplantation, the patient's refusal to receive blood transfusions due to religious reasons and pregnant women's request for voluntary abortions within the first 14 weeks.

CONCLUSION

Nurses' religious beliefs influence their opinions regarding conscientious objection. The nurses who declare themselves as religious believers object in a higher percentage than those without religious beliefs.

Conscientious object in nursing: Regulations and practice in two European countries

BACKGROUND

The concept of conscientious objection is well described; however, because of its nature, little is known about real experiences of nursing professionals who apply objections in their practice. Extended roles in nursing indicate that clinical and value-based dilemmas are becoming increasingly common. In addition, the migration trends of the nursing workforce have increased the need for the mutual understanding of culturally based assumptions on aspects of health care delivery.

AIM

To present (a) the arguments for and against conscientious objection in nursing practice, (b) a description of current regulations and practice regarding conscientious objection in nursing in Poland and the United Kingdom, and (c) to offer a balanced view regarding the application of conscientious objection in clinical nursing practice.

DESIGN

Discussion paper.

ETHICAL CONSIDERATIONS

Ethical guidelines has been followed at each stage of this study.

FINDINGS

Strong arguments exist both for and against conscientious objection in nursing which are underpinned by empirical research from across Europe. Arguments against conscientious objection relate less to it as a concept, but rather in regard to organisational aspects of its application and different mechanisms which could be introduced in order to reach the balance between professional and patient's rights.

DISCUSSION AND CONCLUSION

Debate regarding conscientious objection is vivid, and there is consensus that the right to objection among nurses is an important, acknowledged part of nursing practice. Regulation in the United Kingdom is limited to reproductive health, while in Poland, there are no specific procedures to which nurses can apply an objection. The same obligations of those who express conscientious objection apply in both countries, including the requirement to share information with a line manager, the patient, documentation of the objection and necessity to indicate the possibility of receiving care from other nurses. Using Poland and the United Kingdom as case study countries, this article offers a balanced view regarding the application of conscientious objection in clinical nursing practice.

[Perception of medical students in Galicia (Spain) regarding conscientious objection to the voluntary termination of pregnancy]

OBJECTIVE

To discover whether future doctors in Galicia (Spain) are willing to express conscientious objection to voluntary termination of pregnancy (VTP). The medical students' level of knowledge regarding conscientious objection in health care was also examined, and their knowledge regarding the costs patients would incur if unable to exercise their right to VTP.

METHOD

Cross-sectional study by conducting a survey of 350 medical students in the 2nd and the 5th years of the Degree in Medicine at the University of Santiago de Compostela, in the academic year 2017-2018.

RESULTS

70.8% of those surveyed would not declare conscientious objection to VTP. In addition, 70% believe that conscientious objection to VTP can have negative consequences for pregnant women if they are referred from public to private healthcare. However, 72.9% support physicians having the right to declare their conscientious objection to VTP.

CONCLUSIONS

The problem of referring pregnant women to private healthcare, as a consequence of conscientious objection to VTP, is presented as critical in Spain, and in Galicia in particular. The future physicians showed that they strongly favoured not objecting to this healthcare practice, which will enable the problem to be resolved in the near future.

Duty and dilemma: Perioperative nurses hiding an objection to participate in organ procurement surgery

Perioperative nurses assist in organ procurement surgery; however, there is a dearth of information of how they encounter making conscientious objection requests or refusals to participate in organ procurement surgery. Organ procurement surgical procedures can present to the operating room ad hoc and can catch a nurse who may not desire to participate by surprise with little opportunity to refuse as a result of staffing, skill mix or organizational work demands. This paper that stems from a larger doctoral research study exploring the experiences of perioperative nurses participating in multi-organ procurement surgery used a grounded theory method to develop a substantive theory of the nurses' experiences. This current paper aimed to highlight the experiences of perioperative nurses when confronted with expressing a conscientious objection towards their participation in these procedures. A number of organizational and cultural barriers within the healthcare organization were seen to hamper their ability in expressing a conscience-based refusal, which lead to their reluctant participation. Perioperative nurses must feel safe to express a conscientious objection towards these types of surgical procedures and feel supported in doing so by their respective hospital organizations and not be forced to participate unwillingly.

Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents

PURPOSE OF REVIEW

Conscientious objection to reproductive healthcare (refusal to perform abortion, assisted reproductive technologies, prenatal diagnosis, contraception, including emergency contraception and sterilization, etc.) has become a widespread global phenomenon and constitutes a barrier to these services for many women. Adolescents are a particularly vulnerable group because some providers object to specific aspects of their reproductive healthcare because of their status as minors.

RECENT FINDINGS

Recent peer-reviewed publications concerning conscientious objection address provider attitudes to abortion and emergency contraception, ethical arguments against conscientious objection, calls for clarification of the current laws regarding conscientious objection, legal case commentaries, and descriptions of the country-specific impact of policies in Russia and Italy.

SUMMARY

Conscientious objection is understudied, complicated, and appears to constitute a barrier to care, especially for certain subgroups, although the degree to which conscientious objection has compromised sexual and reproductive healthcare for adolescents is unknown. Physicians are well positioned to support individual conscience while honoring their obligations to patients and to medical evidence.

Conscientious objection to referrals for abortion: pragmatic solution or threat to women's rights?

Background

Conscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis.

Methods

Qualitative research interviews were conducted with seven GPs, all Christians. Transcripts were analysed using systematic text condensation.

Results

Informants displayed a marked ambivalence towards their own refusal practices. Five main topics emerged in the interviews: 1) carrying out conscientious objection in practice, 2) justification for conscientious objection, 3) challenges when relating to colleagues, 4) ambivalence and consistency, 5) effects on the doctor-patient relationship.

Conclusions

Norwegian GP conscientious objectors were given to consider both pros and cons when evaluating their refusal practices. They had settled on a practical compromise, the precise form of which would vary, and which was deemed an acceptable middle way between competing interests.