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.

Genetic disenhancement and xenotransplantation: diminishing pigs' capacity to experience suffering through genetic engineering

One objection to xenotransplantation is that it will require the large-scale breeding, raising and killing of genetically modified pigs. The pigs will need to be raised in designated pathogen-free facilities and undergo a range of medical tests before having their organs removed and being euthanised. As a result, they will have significantly shortened life expectancies, will experience pain and suffering and be subject to a degree of social and environmental deprivation. To minimise the impact of these factors, we propose the following option for consideration-ethically defensible xenotransplantation should entail the use of genetic disenhancement if it becomes possible to do so and if that pain and suffering cannot be eliminated by other means. Despite not being a morally ideal 'solution', it is morally better to prevent unavoidable pain until a viable non-animal alternative becomes available.

First among equals? Adaptive preferences and the limits of autonomy in medical ethics

Respect for patient autonomy is a central principle of medical ethics. However, there are important unresolved questions about the characteristics of an autonomous decision, and whether some autonomous preferences should be subject to more scrutiny than others.In this paper, we consider whether inappropriately adaptive preferences-preferences that are based on and that may perpetuate social injustice-should be categorised as autonomous in a way that gives them normative authority. Some philosophers have argued that inappropriately adaptive preferences do not have normative authority, because they are only a reflection of a person's social context and not of their true self. Under this view, medical professionals who refuse to carry out actions which are based on inappropriately adaptive preferences are not in fact violating their patient's autonomy. However, we argue that it is very difficult to articulate a systematic and principled distinction between normal autonomous preferences and inappropriately adaptive preferences, especially if this distinction needs to be useful for clinicians in real-life situations. This makes it difficult to argue that inappropriately adaptive preferences are straightforwardly non-autonomous.Given this problem, we argue that there are significant theoretical issues with contemporary understandings of autonomy in bioethics. We discuss what this might mean for the practice of medicine and for medical ethics education.

Abortion, euthanasia, and the limits of principlism

Principlism is an ethical framework that has dominated bioethical discourse for the past 50 years. There are differing perspectives on its proper scope and limits. In this article, we consider to what extent principlism provides guidance for the abortion and euthanasia debates. We argue that whilst principlism may be considered a useful framework for structuring bioethical discourse, it does not in itself allow for the resolution of these neuralgic policy discussions. Scholars have attempted to use principlism to analyse the ethics and legality of abortion and euthanasia; but such efforts are methodologically problematic. We close with a consideration of the proper scope of principlism in bioethics-a vision that is more modest than the manner in which principlism is often deployed in contemporary academic bioethics and medical education.

An Ethical Examination of Donor Anonymity and a Defence of a Legal Ban on Anonymous Donation and the Establishment of a Central Register

Many if not most sperm donors in the early years of IVF donated under conditions of anonymity. There is, however, a growing awareness of the ethical cost of withholding identifying parental information from donor children. Today, anonymous donation is illegal in many jurisdictions, and some jurisdictions have gone as far as retrospectively invalidating contracts whereby donors were guaranteed anonymity. This article provides a critical evaluation of the ethics and legality of anonymous donation. We defend Australian and British legislation that has outlawed donor anonymity, and we argue for the establishment of a central registry that provides donor children with the ability to easily and reliably access identifying information about their donor parents.

On the importance of consistency: a response to Giubilini et al

Giubilini et al offer some helpful reflections on the conscientious provision of medical care and whether and in what circumstances professional associations ought to support the conscientious provision of abortion in circumstances where abortion is banned or heavily restricted. I have several reservations, however, about the argument developed in the article. First, the essay makes questionable use of the case of Savita Halappanavar to justify its central argument about conscientious provision. Second, there is an apparent inconsistency between this article and the authors' statements elsewhere about the conscientious refusal of care. Third, there are risks that attend to professional associations supporting practitioners who break the law, and yet Giubilini et al do not give sufficient attention to this. This response will briefly discuss these three concerns.

Conscientious Objection in Health Care: Why the Professional Duty Argument is Unconvincing

The past decade has seen a burgeoning of scholarly interest in conscientious objection in health care. Specifically, several commentators have discussed the implications that conscientious objection has for the delivery of timely, efficient, and nondiscriminatory medical care. In this paper, I discuss the main argument put forward by the most prominent critics of conscientious objection-what I call the Professional Duty Argument or PDA. According to proponents of PDA, doctors should place patients' well-being and rights at the center of their professional practice. Doctors should be prepared to set their personal moral or religious beliefs aside where these beliefs conflict with what is legal and considered good medical practice by relevant professional associations. Conscientious objection, on this account, should be heavily restricted, if even allowed at all. I discuss two powerful objections against PDA. The first objection, which I call the fallibility objection, notes that law and professional codes of conduct are fallible guides for ethical conduct and that conscientious objection has in the past and continues today to provide a check on aberrations in law and professional convention. The second, which I call the professional discretion objection, states that restrictions on conscientious objection undermine one of the cornerstones of good medical practice, namely, a practitioner's right to independent professional judgment. I argue that these two objections give us reason to retain conscience clauses in professional codes of conduct.

Vulnerability and Resilience: Phenomenological Analysis of Cancer Patients Value Directives

CONTEXT

Personal values are individual conceptions of the desirable appraisals and actions that guide our attitudes and behaviour. Advance care planning (ACP) now emphasises the consideration of personal life goals and values expressed as a Values Directive (VD) to guide discussions concerning medical treatment.

OBJECTIVE

To investigate the diversity of values, experiences and adaptations expressed in cancer patients VDs.

METHODS

Contents of the VDs of ACPs of cancer patients who participated in a randomised control trial comparing a video intervention showing values communication between cancer patient-caregivers with usual care were analysed. Qualitative phenomenological content analysis was used to understand how participants made meaning of their lived experiences.

RESULTS

Forty-two participants completed an ACP (37.2% response rate), with 97.6% of these completing a VD (57.1% female, mean age 72 years, 30.1% gastrointestinal cancer). Participants described diverse adjustments to frailty and adaptive coping with deteriorating functionality. Emotional and financial concerns were eased through experiencing benevolence and trust established through family and friendship bonds and reciprocation of care. Death anxiety and ambivalence were expressed concurrently with the experiential acceptance of dying. Secular and sacred rituals featured as an affirmation of their faith or beliefs.

CONCLUSION

Cancer patients seek to make meaning of their experiences, concurrently posturing vulnerability and resilience, despite conflicting emotions and experiences. Given that the choices people make as they approach dying relate to their most deeply held values, ACP conversations should explore how patients draw from their values and life goals to optimise their adaptations to illness.

Why Conscience Matters: A Theory of Conscience and Its Relevance to Conscientious Objection in Medicine

Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent's identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living in accord with their own considered understanding of the requirements of morality and undermine one's capacity for moral agency. This article concludes with a consideration of how a robust theory of conscience can inform our understanding of conscientious objection in medicine. I argue that it is in the interest of individual practitioners and the medical profession generally to foster moral agency among doctors. This provides a prima facie justification for permitting at least some kinds of conscientious objection.

An Ethical Defense of a Mandated Choice Consent Procedure for Deceased Organ Donation

Organ transplant shortages are ubiquitous in healthcare systems around the world. In response, several commentators have argued for the adoption of an opt-out policy for organ transplantation, whereby individuals would by default be registered as organ donors unless they informed authorities of their desire to opt-out. This may potentially lead to an increase in donation rates. An opt-out system, however, presumes consent even when it is evident that a significant minority are resistant to organ donation. In this article, we defend a mandated choice framework for consent to deceased organ donation. A mandated choice framework, coupled with good public education, would likely increase donation rates. More importantly, however, a mandated choice framework would respect the autonomous preferences of people who do not wish to donate. We focus in particular on the Australian healthcare context, and consider how a mandated choice system could function as an ethical means to increase the organ donation rate in Australia. We make the novel proposal that all individuals who vote at an Australian federal election be required to state their organ donation preferences when voting.

Persuasion, not coercion or incentivisation, is the best means of promoting COVID-19 vaccination

Savulescu (forthcoming) argues that it may be ethically acceptable for governments to require citizens be vaccinated against COVID-19. He also recommends that governments consider providing monetary or in-kind incentives to citizens to increase vaccination rates. In this response, we argue against mandatory vaccination and vaccine incentivisation, and instead suggest that targeted public health messaging and a greater responsiveness to the concerns of vaccine-hesitant individuals would be the best strategy to address low vaccination rates.

The Content, Teaching Methods and Effectiveness of Spiritual Care Training for Healthcare Professionals: A Mixed-Methods Systematic Review

CONTEXT

Spirituality has been demonstrated to play an important role in healthcare, yet many staff feel ill-equipped to deliver spiritual care. Spiritual care training programs have been developed to address this need.

OBJECTIVE

The aim of this mixed-methods systematic review was to identify spiritual care training programs for healthcare professionals or students, and to investigate program content, teaching methods, key outcomes, and identified challenges and facilitators.

METHODS

A mixed-methods systematic review was conducted. The search terms ('religio*' OR 'spiritual*' OR 'existenti*') were combined with ('educat*' OR 'train*' OR 'curricul*' OR 'program*'), AND ('care' OR 'therap*' OR 'treatment' OR 'competenc*'). Search terms were entered into the following data bases: PsycINFO, Medline, Cinahl and Web of Science. Findings were restricted to peer-reviewed studies published in English between January 2010 and February 2020.

RESULTS

Fifty-five studies were identified. The quality of studies was mixed. Programs encompassed a range of content and teaching methods. Reported outcomes included increased levels of competency across intrapersonal spirituality, interpersonal spirituality, and spiritual assessment and interventions. Identified barriers included competing healthcare priorities, negative perceptions of spirituality and spiritual care, resistance towards focusing on one's own spirituality, staff feeling inadequate, and the need for ongoing training. Facilitators included opportunities for reflection, involvement of chaplains, application of practical tools, opportunities for practice, online training, and managerial support.

CONCLUSIONS

Positive outcomes following spiritual care training were identified. Further research is needed to identify patient-related outcomes of staff training, and to examine how the benefits of such training can be maintained over time.

Why should HCWs receive priority access to vaccines in a pandemic?

Background

Viral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers (HCWs) should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.

Main text

In this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.

Conclusions

We argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs.

Respect for persons and the allocation of lifesaving healthcare resources

Many ethicists argue that we should respect persons when we distribute resources. Yet it is unclear what this means in practice. For some, the idea of respect for persons is synonymous with the idea of respect for autonomy. Yet a principle of respect for autonomy provides limited guidance for how we should distribute scarce medical interventions. In this article, however, I sketch an alternative conception of respect for persons-one that is based on an ethic of mutual accountability. I draw in particular upon Stephen Darwall's writings on respect and the second-person standpoint. I consider the implications of this conception of respect for the distribution of scarce, lifesaving healthcare resources. A second-personal account of respect rules out aggregative approaches to distribution, and instead requires that we give individual consideration to the claims that persons in need make on the resources in our control. The principles that we use to govern our allocation of resources, furthermore, should be principles that are acceptable to all reasonable agents. Building on this insight, the final section of this paper considers how a principle of need can be used as a means to make decisions about the allocation of lifesaving resources.

Reflective disequilibrium: a critical evaluation of the complete lives framework for healthcare rationing

One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer's complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium-a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al's investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives.

Rationing, Responsibility and Blameworthiness: An Ethical Evaluation of Responsibility-Sensitive Policies for Healthcare Rationing

Several ethicists have defended the use of responsibility-based criteria in healthcare rationing. Yet in this article we outline two challenges to the implementation of responsibility-based healthcare rationing policies. These two challenges are, namely, that responsibility for past behavior can diminish as an agent changes, and that blame can come apart from responsibility. These challenges suggest that it is more difficult to hold someone responsible for health related actions than proponents of responsibility-sensitive healthcare policies suggest. We close by discussing public health policies that could function as an alternative to contentious, responsibility-sensitive rationing policies.

'Alive by default': An exploration of Velleman's unfair burdens argument against state sanctioned euthanasia

In this article we critically evaluate an argument against state-sanctioned euthanasia made by David Velleman in his 1992 paper 'Against the right to die'. In that article, Velleman argues that legalizing euthanasia is morally problematic as it will deprive eligible patients of the opportunity of staying 'alive by default'. That is to say, those patients who are rendered eligible for euthanasia as a result of legislative reform will face the burden of having to justify their continued existence to their epistemic peers if they are to be perceived as 'reasonable'. We discuss potential criticisms that could be made of the argument, and consider how a defender of the view might respond. Velleman's argument is particularly interesting as it is a consequentialist argument against state-sanctioned euthanasia, challenging the many consequentialist arguments that have been made in favour of legalizing the procedure. We conclude by suggesting that further research on the question of unfair burdens is important to adequately evaluating the potential harms of legalizing euthanasia for patients at the end of life.

Patients' and Caregivers' Contested Perspectives on Spiritual Care for Those Affected by Advanced Illnesses: A Qualitative Descriptive Study

CONTEXT

Spiritual care refers to practices and rituals addressing spiritual/religious concerns. It supports coping with loss and finding hope, meaning, and peace. Although integral to palliative care, its implementation is challenging.

OBJECTIVE

To understand an Australian cohort of patients' and caregivers' perspectives about experiencing and optimizing spiritual care in the context of advanced illness.

METHODS

Patients and caregivers of patients with ≤12 month prognosis were recruited from a broader spiritual study via criterion sampling and agreed to opt-in interviews. Participants from an Australian, metropolitan health service received a spiritual care definition and were interviewed. Transcripts were analyzed using qualitative description.

RESULTS

30 patients (17 male; mean age 70 years) and 10 caregivers (six male; mean age 58.9 years) participated. 27 identified as Christian, and 10 had no religion. Participants described multifaceted and contested beliefs about spirituality. Many queried the tangibility of spirituality, but all valued respectful staff who affirmed personhood, that is, each individual's worth, especially when care exceeded expectations. They also resonated with positive organizational and environmental tones that improved holistic well-being. Participants stressed the importance of the hospital's welcoming context and skilled care, which comforted and reassured.

CONCLUSION

Although many patients and caregivers did not resonate with the term "spiritual care," all described how the hospital's hospitality could affirm their values and strengthen coping. The phrase "spiritual care and hospitality" may optimally articulate and guide care in similar, pluralist inpatient palliative care contexts, recognizing that such care encompasses an interplay of generalist and specialist pastoral care staff and organizational and environmental qualities.

Pellegrino, MacIntyre, and the internal morality of clinical medicine

There has been significant debate about whether the moral norms of medical practice arise from some feature or set of features internal to the discipline of medicine. In this article, I analyze Edmund Pellegrino's conception of the internal morality of medicine, and situate it in the context of Alasdair MacIntyre's influential account of "practice." Building upon MacIntyre, Pellegrino argued that medicine is a social practice with its own unique goals-namely, the medical, human, and spiritual good of the patient-and that the moral norms that govern medical practice are derived from these goals. After providing an overview of Pellegrino's work, I discuss some forceful objections to his theory-specifically, that it is too rigid and incapable of entering into dialogue with contemporary values systems; that it is dependent on an external conception of human flourishing; and that it is incompatible with the rapidly changing nature of modern medicine. In the final section of this article, I consider how theorists working in the Hippocratic tradition might respond to these objections against ethical essentialism by drawing upon MacIntyre's historico-cultural method as well as what he calls Aristotle's "metaphysical biology."

Organismal death, the dead-donor rule and the ethics of vital organ procurement

Several bioethicists have recently discussed the complexity of defining human death, and considered in particular how our definition of death affects our understanding of the ethics of vital organ procurement. In this brief paper, we challenge the mainstream medical definition of human death-namely, that death is equivalent to total brain failure-and argue with Nair-Collins and Miller that integrated biological functions can continue even after total brain failure has occurred. We discuss the implications of Nair-Collins and Miller's argument and suggest that it may be necessary to look for alternative biological markers that reliably indicate the death of a human being. We reject the suggestion that we should abandon the dead-donor criteria for organ donation. Rather than weaken the ethical standards for vital organ procurement, it may be necessary to make them more demanding. The aim of this paper is not to justify the dead donor rule. Rather, we aim to explore the perspective of those who agree with critiques of the whole brain and cardiopulmonary definitions of death but yet disagree with the proposal that we should abandon the dead-donor rule. We will consider what those who want to retain the dead-donor rule must argue in light of Nair-Collins and Miller's critique.

Extending Awareness of Catholic Healthcare Ethics Among Junior Clinicians: A Qualitative Study

As Catholic healthcare organizations form a substantive part of healthcare delivery in the USA and Australia, ethical standards for Catholic health care were developed to guide practice. This study examined junior staff's understanding of Catholic ethics. Using a qualitative descriptive design, we recruited 22 medical and nursing staff to interviews/focus groups. Though Catholic ethics seldom informed ethical approaches, the principles were acknowledged as being useful to support development of confident and respectful care approaches. Findings provide early insights into challenges faced in considering implementation of ethical codes across both secular and religious healthcare organizations, suggesting that a more creative and pastoral approach to dialoguing and implementing Catholic ethics is required.

Does the doctrine of double effect apply to the prescription of barbiturates? Syme vs the Medical Board of Australia

The doctrine of double effect (DDE) is a principle of crucial importance in law and medicine. In medicine, the principle is generally accepted to apply in cases where the treatment necessary to relieve pain and physical suffering runs the risk of hastening the patient's death. More controversially, it has also been used as a justification for withdrawal of treatment from living individuals and physician-assisted suicide. In this paper, I will critique the findings of the controversial Victorian Civil and Administrative Tribunal (VCAT) hearing Syme vs the Medical Board of Australia In that hearing, Dr Rodney Syme, a urologist and euthanasia advocate, was defending his practice of prescribing barbiturates to terminally ill patients. Syme claimed that he prescribed the drugs with the intention of relieving their existential suffering and not to assist in suicide; he argued that the DDE could be applied. Pace VCAT, I argue that this is an illegitimate application of DDE. I argue that a close scrutiny of Syme's actions reveals that, at the very least, he intended to give patients the option of suicide. He furthermore used what on a traditional definition of DDE would be considered a 'bad' means-the prescription of Nembutal-to achieve a 'good' end-the relief of suffering. The case demonstrates the crucial importance of analysing an agent's 'intention' and the 'effects' of their actions when applying DDE. Ethicists and, indeed, the judiciary need to attend to the ethical complexities of DDE when they assess the applicability of DDE to end of life care. If they fail to do this, the doctrine risks losing its legitimacy as an ethical principle.

Two conceptions of conscience and the problem of conscientious objection

Schuklenk and Smalling argue that it is practically impossible for civic institutions to meet the conditions necessary to ensure that conscientious objection does not conflict with the core principles of liberal democracies. In this response, I propose an alternative definition of conscience to that offered by Schuklenk and Smalling. I discuss what I call the 'traditional' notion of conscience, and contrast this with the existentialist conception of conscience (which I take to be a close cousin of the view targeted by Schuklenk and Smalling). I argue that the traditional notion, grounded in an objective moral order, avoids the criticisms advanced by Schuklenk and Smalling; the existentialist conception, in contrast, does not. I conclude by discussing the benefits and risks of a 'restricted view' of respect for conscience.

On the univocity of rationality: a response to Nigel Biggar's 'Why religion deserves a place in secular medicine'

Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we abandon the standard rationalistic conception of the secular realm and see it rather as "a forum for the negotiation of rival reasonings". Religious reasoning is one among a number of ways of thinking that must vie for acceptance. Medical ethics, says Biggar, is characterised by "spiritual and moral mixture and ambiguity". We acknowledge this uncertainty by recognising rival viewpoints and agreeing to provisional compromises.In this response, I object to Biggar's characterisation of medical ethics as "morally ambiguous" and "provisional". I argue that Biggar has failed to provide adequate support for his conception of ethics as a "forum for negotiation and compromise". I criticise Biggar's attempt to 'pluralise' rationality, and assert that if religion is to play a role in secular medicine, it must be ready to defend itself against a universal standard of reason. In the second section of my response, I argue that 'theistic natural law' gives us the resources to defend using reason alone ostensibly faith-based positions in healthcare ethics. In doing so, we retain a univocal conception of rationality, while at the same time leaving space for 'theism' in healthcare ethics.