Conflicts of Conscience in Health Care

Conflicts of Conscience in Health Care: An Institutional Compromise

Holly Fernandez Lynch
Series: Basic Bioethics
Copyright Date: 2008
Published by: MIT Press
Pages: 368
https://www.jstor.org/stable/j.ctt5hhf0c
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  • Book Info
    Conflicts of Conscience in Health Care
    Book Description:

    Physicians in the United States who refuse to perform a variety of legally permissible medical services because of their own moral objections are often protected by "conscience clauses." These laws, on the books in nearly every state since the legalization of abortion by Roe v. Wade, shield physicians and other health professionals from such potential consequences of refusal as liability and dismissal. While some praise conscience clauses as protecting important freedoms, opponents, concerned with patient access to care, argue that professional refusals should be tolerated only when they are based on valid medical grounds. In Conflicts of Conscience in Health Care, Holly Fernandez Lynch finds a way around the polarizing rhetoric associated with this issue by proposing a compromise that protects both a patient's access to care and a physician's ability to refuse. This focus on compromise is crucial, as new uses of medical technology expand the controversy beyond abortion and contraception to reach an increasing number of doctors and patients. Lynch argues that doctor-patient matching on the basis of personal moral values would eliminate, or at least minimize, many conflicts of conscience, and suggests that state licensing boards facilitate this goal. Licensing boards would be responsible for balancing the interests of doctors and patients by ensuring a sufficient number of willing physicians such that no physician's refusal leaves a patient entirely without access to desired medical services. This proposed solution, Lynch argues, accommodates patients' freedoms while leaving important room in the profession for individuals who find some of the capabilities of medical technology to be ethically objectionable.

    eISBN: 978-0-262-27872-0
    Subjects: Biological Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Series Foreword
    (pp. ix-x)
    Glenn McGee and Arthur Caplan

    We are pleased to present the twenty-fourth book in the series Basic Bioethics. The series presents innovative works in bioethics to a broad audience and introduces seminal scholarly manuscripts, state-of-the-art reference works, and textbooks. Such broad areas as the philosophy of medicine, advancing genetics and biotechnology, end-of-life care, health and social policy, and the empirical study of biomedical life are engaged....

  4. Preface
    (pp. xi-xiv)
  5. Acknowledgments
    (pp. xv-xvi)
  6. Introduction
    (pp. 1-16)

    Over a decade ago, outside the heated context of the current debate surrounding professional refusal clauses, Pope John Paul II made a powerful statement about the nature of conscience, complicity in morally objectionable actions, and avoidance of injustice, which can be generally accepted by both the religious and nonreligious alike, located at nearly every point along the political spectrum. He opined that “to refuse to take part in committing an injustice is not only a moral duty, it is also a basic human right. Were this not so, the human person would be forced to perform an action intrinsically incompatible...

  7. I Conscience Clauses and Professionalism
    • 1 A Primer on Conscience Clauses
      (pp. 19-42)

      For obvious reasons, conscience plays a major role in ethical endeavors, and those within the realm of bioethics are certainly no exception. Conscience frequently rears its head in bioethical decision making since these choices often raise deep questions about life and death, God and science, tradition and technology. Further complicating matters is the fact that doctors and their patients may hold widely disparate perspectives on these issues, but only one course of action can be chosen, which often cannot be taken back and which may have lasting consequences for either or both parties. For these reasons, some find it hard...

    • 2 Defining Medical Professionalism
      (pp. 43-76)

      Professionalism is an integral component of the conscience clause debate, which at its heart asks whether being a medical professional demands the willingness always to place others before oneself and whether personal or professional norms take precedence. However, professional obligations are an incredibly tricky concept to characterize, and nearly everyone, including doctors themselves, struggles to adequately and accurately explain the terrain. Unfortunately, they often can do little more than fall back on Justice Potter Stewart’s definition of obscenity; they may not be able to define professionalism intelligibly, but they know it when they see it—or better yet, they know...

  8. II Protecting Doctors and Patients:: An Institutional Solution
    • 3 Moral Diversity in Medicine and the Ideal of Doctor-Patient Matching
      (pp. 79-98)

      Given that making medical services available to the public is a fundamental responsibility of the medical profession, we must ask how we can secure such availability in the context of the moral opposition felt by some members of that profession to some of the services patients may seek. One option might be to explore elimination of the collective professional monopoly held by physicians in many controversial areas. In fact, because physicians have failed to adequately provide access to some important services for women, a handful of states have decided to allow nurses and other trained health-care professionals to perform abortions...

    • 4 Which Institution? Licensing Boards Bearing the Burdens of Conscience and Access
      (pp. 99-114)

      So far, we have established that there is an important role for personal morality in the practice of medicine and that it would be far too harsh to expect the medical profession to satisfy its collective obligations to the public by excluding physicians who are opposed to the provision of particular medical services, at least without first exploring other options. Implementation of doctor-patient matching would be an important step in the right direction, but while matching is the ideal, we have not yet seen how the prerequisite of patient access can be satisfied. We begin down that road now, learning...

  9. III The Details of the Institutional Solution
    • 5 Measuring Patient Demand and Determining Which Demands to Meet
      (pp. 117-144)

      Because conflicts of conscience in medicine can be alternatively framed as a function of nothing more than mismatched supply and demand for physician services, one solution is to make sure that there is a sufficient supply of competent, willing physicians so that patients desiring a particular medical service can realistically obtain it.¹ If this task can be accomplished, we have seen that there is no reason to demand that individual physicians deliver care in conflict with their conscience, and in fact, that there may be several reasons to allow physicians to refuse. However, as is so often the case, pinpointing...

    • 6 Measuring Physician Supply and Limiting the Grounds for Physician Refusal
      (pp. 145-164)

      Once licensing boards have determined which patient demands they have an obligation to meet and the level of demand for those medical services, their next step toward ensuring sufficient access despite conscientious refusals will be to measure the supply of physicians willing to provide those services. As was the case with measuring patient demand, measuring physician supply should prove relatively simple as a technical matter, with normative concerns getting the brunt of our attention instead. Here we consider which limitations on supply—which grounds for conscientious refusal—boards should accept as legitimate.

      Because refusing physicians are opting to narrow their...

    • 7 Calibrating Supply and Demand
      (pp. 165-194)

      While the tasks of determining which patient access demands licensing boards should be responsible for meeting and which physician refusals they should be willing to accept present some difficult normative questions, other definitional and measurement concerns remain. In order to know where to measure supply and demand and to determine whether the profession is sufficiently addressing those patient access concerns stemming from conscientious refusal, geographic boundaries must be established. If patients demand abortions, for example, how far is too far to expect women to go to find a willing provider before we will say that the licensing board has unacceptably...

    • 8 The “Hard” Cases: When the Institutional Solution Fails
      (pp. 195-214)

      We have now seen what is expected of the licensing board, but what if it fails to remedy patient access problems in the way that is expected of it because the board is not appropriately working to resolve shortages or maldistribution of willing physicians, or it simply has not yet been successful in doing so? Patients will be left without reasonable access to services that we have determined they have an interest in receiving, if not a right, and we are left to decide among only second-best solutions, namely, (1) eliminating the option for conscientious refusal by physicians in these...

    • 9 Physician Obligations and Sacrifices
      (pp. 215-240)

      So far, we have explored the ways that licensing boards can offer a promising, albeit imperfect, solution to the conscience clause dilemma currently facing the medical profession. But while these boards will clearly bear a great deal of responsibility, physicians themselves must bear some burdens of their own in order to be free of liability to patients or other consequences stemming from the exercise of conscientious refusal. There are some professional duties that are not only collective, but rather truly are applicable to—and ought to be enforceable against—each individual physician.

      In addition to refraining from refusals based on...

    • 10 Addressing Skeptics, a Model Statute, and Conclusions
      (pp. 241-258)

      The preceding chapters have demonstrated that not only is it normatively ideal to simultaneously accommodate the interests of both doctors and patients, allowing physicians to engage in conscientious refusal and preserving patient access to medical services, but also that it is possible to craft a feasible mechanism for doing so. This final chapter offers a model statute to serve as a guide to state legislatures interested in combating the current conscience clause dilemma, which will need to be supplemented by specific regulations adapted to the circumstances faced by various state licensing boards. Without a doubt, this proposal challenges vested political...

  10. Appendix: Statutes, Regulations, and Case Law
    (pp. 259-262)
  11. Notes
    (pp. 263-316)
  12. References
    (pp. 317-334)
  13. Index
    (pp. 335-346)