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Theoretical Medicine and Bioethics

, Volume 39, Issue 2, pp 143–155 | Cite as

Conscientious objection and person-centered care

  • Stephen BuetowEmail author
  • Natalie Gauld
Article
  • 372 Downloads

Abstract

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

Keywords

Conscience Refusal to treat Ethics Medical Person-centered care 

Notes

Acknowledgements

The authors wish to thank the Editor and anonymous reviewers of an earlier version of this article for their first-rate feedback and support. The authors also wish to thank the Managing Editor of the journal, Katelyn MacDougald, for her exceptional work on the final version of this paper.

References

  1. 1.
    Sharpsteen, Ben, Hamilton Luske, Bill Roberts, Norman Ferguson, Jack Kinney, Wilfred Jackson, and T. Hee (dirs.). 1940. Pinocchio. Burbank, CA: Walt Disney.Google Scholar
  2. 2.
    Clarke, Steve. 2017. Two concepts of conscience and their implications for conscience-based refusal in healthcare. Cambridge Quarterly of Healthcare Ethics 26: 97–108.CrossRefGoogle Scholar
  3. 3.
    Hill, Thomas E., Jr. 1998. Four conceptions of conscience. Nomos 40: 13–52.Google Scholar
  4. 4.
    Seager, William. 2002. Emotional introspection. Consciousness and Cognition 11: 666–687.CrossRefGoogle Scholar
  5. 5.
    Sulmasy, Daniel P. 2008. What is conscience and why is respect for it so important? Theoretical Medicine and Bioethics 29: 135–149.CrossRefGoogle Scholar
  6. 6.
    Beauchamp, Tom L., and James F. Childress. 2009. Principles of biomedical ethics. 6th ed. Oxford: Oxford University Press.Google Scholar
  7. 7.
    Smith, Vaughan P. 2006. Conscientious objection in medicine: Doctors’ freedom of conscience. BMJ 332: 425.Google Scholar
  8. 8.
    Wicclair, Mark R. 2011. Conscientious objection in health care: An ethical analysis. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  9. 9.
    Savulescu, Julian. 2006. Conscientious objection in medicine. BMJ 332: 294–297.CrossRefGoogle Scholar
  10. 10.
    Stahl, Ronit Y., and Ezekiel J. Emanuel. 2017. Physicians, not conscripts: Conscientious objection in health care. New England Journal of Medicine 376: 1380–1385.CrossRefGoogle Scholar
  11. 11.
    United Nations, Committee on Economic, Social and Cultural Rights. 2000. General Comment No. 14: The right to the highest attainable standard of health (Art. 12 of the International Covenant on Economic, Social and Cultural Rights), E/C.12/2000/4. Geneva: Office of the United Nations High Commissioner for Human Rights. http://www.refworld.org/pdfid/4538838d0.pdf. Accessed 13 July 2018.
  12. 12.
    Munthe, Christian, and Morten Ebbe Juul Nielsen. 2017. The legal ethical backbone of conscientious refusal. Cambridge Quarterly of Healthcare Ethics 26: 59–68.CrossRefGoogle Scholar
  13. 13.
    McQuillan, J.Colin. 2014. Oaths, promises and compulsory duties: Kant’s response to Mendelssohn’s Jerusalem. Journal of the History of Ideas 75: 581–604.CrossRefGoogle Scholar
  14. 14.
    Brock, Dan W., and Allen E. Buchanan. 1987. The profit motive in medicine. Journal of Medicine and Philosophy 12: 1–35.CrossRefGoogle Scholar
  15. 15.
    Minerva, Francesca. 2017. Conscientious objection, complicity in wrongdoing, and a not-so-moderate approach. Cambridge Quarterly of Healthcare Ethics 26: 109–119.CrossRefGoogle Scholar
  16. 16.
    White, Douglas B., and Baruch Brody. 2011. Would accommodating some conscientious objections by physicians promote quality in medical care? Journal of the American Medical Association 305: 1804–1805.CrossRefGoogle Scholar
  17. 17.
    Burwell v. 2014. Hobby Lobby Stores, Inc., 573 U.S. 22.Google Scholar
  18. 18.
    Bedford, Elliott Louis. 2016. The reality of institutional conscience. National Catholic Bioethics Quarterly 16: 255–272.CrossRefGoogle Scholar
  19. 19.
    Durland, Spencer L. 2011. The case against institutional conscience. Notre Dame Law Review 86: 1655–1686.Google Scholar
  20. 20.
    Britton, Joseph Harp. 2013. Abraham Heschel and the phenomenon of piety. London: Bloomsbury.Google Scholar
  21. 21.
    Bardes, Charles L. 2012. Defining “patient-centered medicine.” New England Journal of Medicine 366: 782–783.CrossRefGoogle Scholar
  22. 22.
    Buetow, Stephen. 2016. Person-centred health care: Balancing the welfare of clinicians and patients. London: Routledge.Google Scholar
  23. 23.
    World Health Organization. 2017. Health systems. http://www.who.int/topics/health_systems/en. Accessed 13 July 2018.
  24. 24.
    American Board of Internal Medicine (ABIM) Foundation, American College of Physicians-American Society of Internal Medicine (ACP–ASIM) Foundation, European Federation of Internal Medicine. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136: 243–246.CrossRefGoogle Scholar
  25. 25.
    American Medical Association. 2016. AMA Code of Medical Ethics. https://www.ama-assn.org/delivering-care/ama-code-medical-ethics. Accessed 13 July 2018.
  26. 26.
    Veatch, Robert M. 2006. Character formation in professional education: A word of caution. In Lost virtue: Professional character development in medical education, ed. Nuala Kenny and Wayne Shelton, 29–45. Amsterdam: Elsevier.CrossRefGoogle Scholar
  27. 27.
    American Medical Association. 2014. Report 1 of the Council on Ethical and Judicial Affairs (I-14): Physician exercise of conscience. Chicago: American Medical Association. https://www.ama-assn.org/about-us/patient-physician-relationships-ceja-reports. Accessed 13 July 2018.
  28. 28.
    Berwick, Donald M. 1996. A primer on leading the improvement of systems. BMJ 312: 619–622.CrossRefGoogle Scholar
  29. 29.
    Wendler, David. 2010. Are physicians obligated always to act in the patient’s best interests? Journal of Medical Ethics 36: 66–70.CrossRefGoogle Scholar
  30. 30.
    Gillon, Ranaan. 1986. “The patient’s interests always come first”? Doctors and society. British Medical Journal 292: 398–400.CrossRefGoogle Scholar
  31. 31.
    Rose, Geoffrey. 1992. The strategy of preventive medicine. Oxford: Oxford University Press.Google Scholar
  32. 32.
    Nolan, Tracy L., Jessica J. Kandel, and Don K. Nakayama. 2015. Quality and extent of locum tenens coverage in pediatric surgical practices. American Surgeon 81: 377–380.Google Scholar
  33. 33.
    Wallace, Jean E., Jane B. Lemaire, and William A. Ghali. 2009. Physician wellness: A missing quality indicator. Lancet 374: 1714–1721.CrossRefGoogle Scholar
  34. 34.
    Morton, Natasha T., and Kenneth W. Kirkwood. 2009. Conscience and conscientious objection of health care professionals refocusing the issue. HEC Forum 21: 351–364.CrossRefGoogle Scholar
  35. 35.
    Benn, Piers. 2007. Conscience and health care ethics. In Principles of health care ethics, 2nd ed, ed. Richard Ashcroft, Angus Dawson, Heather Draper, and John McMillan, 345–350. London: Wiley.Google Scholar
  36. 36.
    Strickland, Sophie L.M. 2012. Conscientious objection in medical students: A questionnaire survey. Journal of Medical Ethics 38: 22–25.CrossRefGoogle Scholar
  37. 37.
    Tresolini, Carol P., and Pew-Fetzer Task Force. 1994. Health professions education and relationship-centered care: Report of the Pew-Fetzer task force on advancing psychosocial health education. San Francisco: Pew Health Professions Commission.Google Scholar
  38. 38.
    Beach, Mary Catherine, Thomas Inui, and Relationship-Centered Care Research Network. 2006. Relationship-centered care: A constructive reframing. Journal of General Internal Medicine 21: S3–S8.Google Scholar
  39. 39.
    Buetow, Stephen, and Glyn Elwyn. 2008. The window mirror: A new model of the patient-physician relationship. Open Medicine 2: E20–E25.Google Scholar
  40. 40.
    Smith, Christian. 2015. To flourish or destruct: A personalist theory of human goods, motivations, failure, and evil. Chicago: University of Chicago Press.CrossRefGoogle Scholar
  41. 41.
    Curtler, Hugh Mercer. 1994. Can virtue be taught? Humanitas 7: 43–50.Google Scholar
  42. 42.
    Hardt, John J. 2008. The conscience debate: Resources for rapprochement from the problem’s perceived source. Theoretical Medicine and Bioethics 29: 151–160.CrossRefGoogle Scholar
  43. 43.
    Sulmasy, Daniel P. 2006. Emergency contraception for women who have been raped: Must Catholics test for ovulation, or is testing for pregnancy morally sufficient? Kennedy Institute of Ethics Journal 16: 305–331.CrossRefGoogle Scholar
  44. 44.
    Tylor, Edward B. 1871. Primitive culture: Researches in the development of mythology, philosophy, religion, language, art and custom. London: John Murray.Google Scholar
  45. 45.
    George, Daniel, Iahn Gonsenhauser, and Peter Whitehouse. 2006. Medical professionalism: The nature of story and the story of nature. In Professionalism in medicine: Critical perspectives, ed. Delese Wear and Julie M. Aultman, 63–86. New York: Springer.CrossRefGoogle Scholar
  46. 46.
    Minerva, Francesca. 2015. Conscientious objection in Italy. Journal of Medical Ethics 41: 170–173.CrossRefGoogle Scholar
  47. 47.
    Weitz, Tracy A., Diana Taylor, Sheila Desai, Ushma D. Upadhyay, Jeff Waldman, Molly F. Battistelli, and Eleanor A. Drey. 2013. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. American Journal of Public Health 103: 454–461.CrossRefGoogle Scholar
  48. 48.
    Gauld, Natalie J., Fiona S. Kelly, Nahoko Kurosawa, Linda J.M. Bryant, Lynne M. Emmerton, and Stephen A. Buetow. 2014. Widening consumer access to medicines through switching medicines to non-prescription: A six country comparison. PLoS ONE 9: e107726.  https://doi.org/10.1371/journal.pone.0107726.CrossRefGoogle Scholar
  49. 49.
    Duggan, Patrick S., Gail Geller, Lisa A. Cooper, and Mary Catherine Beach. 2006. The moral nature of patient-centeredness: Is it “just the right thing to do”? Patient Education and Counseling 62: 271–276.CrossRefGoogle Scholar
  50. 50.
    Pellegrino, Edmund D., and David C. Thomasma. 1993. The virtues in medical practice. New York: Oxford University Press.Google Scholar
  51. 51.
    Toon, Peter D. 1999. Towards a philosophy of general practice: A study of the virtuous practitioner. Occasional paper 78. London: Royal College of General Practitioners.Google Scholar
  52. 52.
    Marcum, James A. 2012. The virtuous physician: The role of virtue in medicine. Dordrecht: Springer.CrossRefGoogle Scholar
  53. 53.
    Arthur, James, Kristján Kristjánsson, Hywel Thomas, Ben Kotzee, Agnieszka Ignatowicz, and Tian Qiu. 2015. Virtuous medical practice. Birmingham: University of Birmingham. https://www.jubileecentre.ac.uk/userfiles/jubileecentre/pdf/Research%20Reports/Virtuous_Medical_Practice.pdf. Accessed 13 July 2018.
  54. 54.
    Pellegrino, Edmund D., and David C. Thomasma. 1988. For the patient’s good: The restoration of beneficence in health care. New York: Oxford University Press.Google Scholar
  55. 55.
    Goodstein, Jerry D. 2000. Moral compromise and personal integrity: Exploring the ethical issues of deciding together in organizations. Business Ethics Quarterly 10: 805–819.CrossRefGoogle Scholar
  56. 56.
    Aquinas, Thomas. 2006. Summa theologiae, vol. 23, ed. W.D. Hughes. Cambridge: Cambridge University Press.Google Scholar
  57. 57.
    Sulmasy, Daniel P. 2017. Tolerance, professional judgment, and the discretionary space of the physician. Cambridge Quarterly of Healthcare Ethics 26: 18–31.CrossRefGoogle Scholar
  58. 58.
    Robinson, Bruce A. 1997. Roman Catholicism and abortion access: Possible exceptions to the ban on abortion by the Roman Catholic Church. Religious Tolerance. Updated December 11, 2011. http://www.religioustolerance.org/abo_hist_c1.htm.
  59. 59.
    Hursthouse, Rosalind. 1991. Virtue theory and abortion. Philosophy and Public Affairs 20: 223–246.Google Scholar
  60. 60.
    Thomson, Judith Jarvis. 1971. A defense of abortion. Philosophy and Public Affairs 1: 47–66.Google Scholar
  61. 61.
    Koestner, Richard, and Gaёtan F. Losier. 1996. Distinguishing reactive versus reflective autonomy. Journal of Personality 64: 465–494.CrossRefGoogle Scholar
  62. 62.
    Kukla, Rebecca. 2005. Conscientious autonomy: Displacing decisions in healthcare. Hastings Center Report 35: 34–44.CrossRefGoogle Scholar
  63. 63.
    Nordberg, Eva M., Helge Skirbekk Kibsgaard, and Morten Magelssen. 2014. Conscientious objection to referrals for abortion: Pragmatic solution or threat to women’s rights? BMC Medical Ethics 15: 15.  https://doi.org/10.1186/1472-6939-15-15.CrossRefGoogle Scholar
  64. 64.
    Lyus, Richard John. 2017. Response to: ‘Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies’ by Schuklenk and Smalling. Journal of Medical Ethics 43: 250–252.CrossRefGoogle Scholar
  65. 65.
    Chervenak, Frank A., and Laurence B. McCullough. 2008. The ethics of direct and indirect referral for termination of pregnancy. American Journal of Obstetrics and Gynecology 199: 232.e1–232.e3.CrossRefGoogle Scholar
  66. 66.
    Hersh, Eitan D., and Matthew N. Goldenberg. 2016. Democratic and Republican physicians provide different care on politicized health issues. Proceedings of the National Academy of Sciences 113: 11811–11816.CrossRefGoogle Scholar
  67. 67.
    Veatch, Robert M. 1995. Abandoning informed consent. Hastings Center Report 25: 5–12.CrossRefGoogle Scholar
  68. 68.
    Malterud, Kirsti, and Hanne Hollnagel. 2005. The doctor who cried: A qualitative study about the doctor’s vulnerability. Annals of Family Medicine 3: 348–352.CrossRefGoogle Scholar
  69. 69.
    Pitts, Leonard, Jr. 2016. The middle ground in the abortion argument. Seattle Times, February 14. https://www.seattletimes.com/opinion/the-middle-ground-in-the-abortion-argument. Accessed 13 July 2018.
  70. 70.
    Buchbinder, Mara, Dragana Lassiter, Rebecca Mercier, Amy Bryant, and Anne Drapkin Lyerly. 2016. Reframing conscientious care: Providing abortion care when law and conscience collide. Hastings Center Report 46: 22–30.CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  1. 1.Department of General Practice and Primary Health CareUniversity of AucklandAucklandNew Zealand
  2. 2.Queen Margaret UniversityEdinburghScotland, UK
  3. 3.School of Pharmacy, and Department of PediatricsUniversity of AucklandAucklandNew Zealand

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