Assistance in Elective Termination of Pregnancy
The Problems of Conscientious Objection
Conscientious objection, in the context of the nursing environment, is a situation in which a nurse does not feel comfortable with his or her role in a particular medical procedure. The topic of discussion here will be elective termination of pregnancy, or colloquially speaking, abortion (Wicclair, 2011). There are many reasons that nurses or other medical professionals may choose to object to certain medical procedures, but the issue of abortion is easily the one that becomes the most problematic in many countries (Wicclair, 2011). Different countries have different rules regarding the existence of conscientious objection; some doctors and nurses in certain places are free to object and remove themselves, so to speak, from any procedure that makes them feel uncomfortable; other places have much stricter rules regarding what is allowed and acceptable for a conscientious objector (Wicclair, 2007).
One standard that is commonly set in western countries that have high standards for health care is the standard that a doctor or nurse cannot decline participation in a medical intervention that will save a life or prevent continuing health; for the purposes of discussion here, the topic will encompass only elective termination of pregnancy, not termination of pregnancy that occurs for the safety of the mother, like ectopic pregnancy (Cook, Olaya & Dickens, 2009). There are a number of fail safes that are put in place to protect both patients and doctors that are in the situation of conscientious objection to termination of pregnancy; some of these strategies-especially the most fiscally, ethically, and socially viable ones-are addressed here. They are broken down into authoritative solutions, economic solutions, and collaborative solutions, so best to determine the strengths and weaknesses of each particular strategy. The problem of conscientious objection is known as a wicked problem, because in solving it, there are many other problems that are created; there is no good solution to the problem, as it is compounded by a number of other issues.
There is no doubt that the conscientious objection rights of medical professionals have caused problems since the introduction of abortion into the mainstream in the United States. In the United States, 45 states have laws that allow for conscientious objection to abortion; for the most part, doctors, nurses, and nurse practitioners in these states have a legal requirement to provide a referral for their patient if they themselves are unwilling to perform a particular procedure (Charo, 2005). However, in recent years, there has even been push back against this policy of referring patients to a different doctor (Curlin et al., 2007). Curlin et al. (2007) write, “Many physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures. Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests” (Curlin et al., 2007). The push back against the requirements set forth in the conscientious objector laws has been so hard that many doctors and other healthcare providers are now seeing themselves as complicit if they even provide a patient with a referral.
However, despite these problems, the United States has protections in place that guarantee a woman the right to have an abortion under certain circumstances. By refusing to participate in the referral of a patient to another doctor who will willingly perform the procedure, a medical professional that is acting under moral obligation is acting in such a way that they are denying a patient a right that is guaranteed to them
(Curlin et al., 2007). A good authoritative solution to the problem of conscientious objection is to continue the practice of requiring-legally requiring-a doctor or nurse unwilling to perform a procedure to provide the patient with a referral (Curlin et al., 2007).
The rules enacted regarding conscientious objection have had little care for the effects of a doctor or nurse’s refusal on a patient’s rights. Re-establishing these rights for the patient is particularly important, and in some case, legal and authoritative requirements are the only way to establish healthy practices (Dickens & Cook, 2007).
Some would argue that there are a number of ways that the economy and the medical community will begin to regulate themselves; one argument is that there will be a distinct market for those who have no moral qualms about terminating a pregnancy (Zampas & Andion-Ibanez, 2012). However, the community that believes that abortion is immoral is very strong, and has had serious impacts on the current policies that exist regarding abortion; indeed, conscientious objection was the cause of almost complete termination of abortion services in South Australia in the late 1980s (Cannold, 1994).
The disruption of services is not one that can be overcome with an economic solution. Cannold (1994) writes, “In cases of health care professional conscientious refusal, it is argued that a balance must be struck between the HCPs’ claims to autonomous action and the consequences to them of having their autonomous actions restricted, and the entitlement of patients to care and the consequences of them being refused care. Conscientious action that results in the termination or disruption of health care services, however, is always impermissible on two grounds…” (Cannold, 1994). The patient is put at serious risk as a result of the medical inaction, and the refusal becomes a political action-both of these things should be kept very far from the health care field. There is no economic solution that can overcome the political statement that is made as a result of conscientious objection; this is one of the main problems of an economic solution to the issue of conscientious objection as a whole.
Proponents of collaborative solutions hope to establish a universal definition of morality, insofar as the performance of elective terminations are concerned. As it stands in American culture, the idea of conscience and liberty are very independent, personal concepts; there is no single, universal idea of liberty and conscience in American society.
Currently, as it stands, there are certain standards that are set by the American government insofar as the ethics of medicine are concerned (Dickens & Cook, 2000). Dickens and Cook (2000) write, “Nurses’ conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid” (Dickens & Cook, 2000). Essentially, the literature suggest that merely having a conscientious objection to elective termination is not a problem for a doctor or a nurse; however, refusing a patient care in any one of a plethora of different ways is where the moral and ethical problem arises for the health care professional in question (Dickens & Cook, 2000). Nurses are sometimes forced to do things they find ethically unacceptable; protections for these individuals are particularly important to avoid burn out (Catlin et al., 2008).
Finding collaborative solutions can be difficult because of the difficult nature of morality and ethics, especially in the case of abortion. Medical institutions have an important job in outlining the necessarily
ethical and moral requirements that exist for their staff, including doctors, nurses, nurse practitioners, and other individuals that work in patient-facing positions, like pharmacists. Outlining the ethical requirements that these people must follow protects the institution, the patient, and the medical professional (Dickens & Cook, 2000).
Discussion and Conclusions
When doctors, nurses, patients, and healthcare institutions are able to work together to find a solution that works well for the all the participants, there are few problems associated with the idea of conscientious objection. However, more often than not, the research has demonstrated that conscientious objection is used for political statements, not only for personal, ethical statements (Cannold, 1994; Charo, 2005; Wicclair, 2007; Wicclair, 2011). The inclusion of political statements into the realm of medical treatment is very problematic, and should be avoided for a number of reasons (Charo, 2005).
Requiring all doctors and nurses to facilitate elective termination for their patients seems unlikelyhowever, the law can and should require doctors to provide patients with referrals, and also to provide patients with information about their rights as a patient (Cook, Olaya, & Dickens, 2009). Greater patient awareness and assertion is one way that the medical community is forced to maintain a high standard of care, regardless of the personal beliefs of the medical professionals involved. The rights of an individual doctor are important, but so too are the rights of the patients-the latter must be protected just as heavily as the former. In solving this wicked problem, it is necessary to curtail some of the rights of doctors as conscientious objectors, because there are issues with patients and their ability to obtain good care. Forcing doctors to provide referrals creates fewer problems than removing the conscientious objector policies; however, it puts more of the burden on the individual.
Cannold, L. (1994). Consequences for patients of health care professionals’ conscientious actions: the ban on abortions in South Australia. Journal Of Medical Ethics, 20(2), 80-86. doi:10.1136/jme.20.2.80 Catlin, A., Volat, D., Hadley, M., Bassir, R., Armigo, C., & Valle, E. et al. (2008). Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders That Cause Suffering at the End of Life? Study of a Concept. Neonatal Network: The Journal Of Neonatal Nursing, 27(2), 101-108. doi:10.1891/0730-08220.127.116.11 Charo, R. (2005). The Celestial Fire of Conscience – Refusing to Deliver Medical Care. New England Journal Of Medicine, 352(24), 2471-2473. doi:10.1056/nejmp058112 Cook, R., Arango Olaya, M., & Dickens, B. (2009). Healthcare responsibilities and conscientious objection. International Journal Of Gynecology & Obstetrics, 104(3), 249-252. doi:10.1016/j.ijgo.2008.10.023 Curlin, F., Lawrence, R., Chin, M., & Lantos, J. (2007). Religion, Conscience, and Controversial Clinical Practices. New England Journal Of Medicine, 356(6), 593-600. doi:10.1056/nejmsa065316 Dickens, B., & Cook, R. (2000). The scope and limits of conscientious objection. International Journal Of Gynecology & Obstetrics, 71(1), 71-77. doi:10.1016/s0020-7292(00)00330-1 Hanna, D. (2005). The Lived Experience of Moral Distress: Nurses Who Assisted With Elective Abortions. Res Theory Nurs Prac, 19(1), 95-124. doi:10.1891/rtnp.18.104.22.168335
Wicclair, M. (2007). The Moral Significance of Claims of Conscience in Healthcare. The American Journal Of Bioethics, 7(12), 30-31. doi:10.1080/15265160701710121 Wicclair, M. (2011). Conscientious objection in health care. Cambridge: Cambridge University Press. Zampas, C., & Andion-Ibanez, X. (2012). Conscientious Objection to Sexual and Reproductive Health Services: International Human Rights Standards and European Law and Practice. European Journal Of Health Law, 19(3), 231-256. doi:10.1163/157180912×639116