Provider Conscientious Refusal of Abortion,Obstetrical Emergencies,and Criminal Homicide Law

Catholic doctrine’s strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials.     

Conscience and conscientious actions in the context of MCOs

Managed care organizations can produce conflicts of obligation and conflicts of interest that may lead to problems of conscience for health care professionals. This paper provides a basis for understanding the notions of conscience and conscientious objection and offers a framework for clinicians to stake out positions grounded in personal conscience as a way for them to respond to unacceptable pressures from managers to limit services.     

Conscientious objection and emergency contraception

This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested.     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

Conscientious Objection and the Morning‐After Pill

The so‐called ‘morning‐after pill’ is a drug that prevents pregnancy if taken no later than 72 hours after presumably fertile sexual intercourse. This article argues against a right of conscientious objection for pharmacists with regard to dispensing this drug. Some arguments that might be advanced in support of this right will be considered and rejected. Section 2 argues that from a philosophical point of view, the most relevant question is not whether the morning‐after pill prevents implantation nor is it whether preventing implantation is tantamount to abortion. Section 3 suggests a more general philosophical question as most pertinent, namely whether and to what extent a pharmacist can justifiably be exempted from dispensing the morning‐after pill when to do so would entail participating in something that goes against his or her deepest moral or religious convictions. Section 4 explains why, within liberal institutions, pharmacists should not have the right to conscientious objection to dispensing the morning‐after pill.     

The promises and perils of pragmatism: commentary on Fins, Bacchetta, and Miller

Fins, Bacchetta, and Miller's clinical pragmatism has several appealing features: an emphasis on dialogue, a commitment to consensus, a focus on particular individuals rather than persons in general, and a strong interest in the process as well as the product of moral decision making. Nevertheless, for all its protests to the contrary, clinical pragmatism has a tendency to privilege medical facts over nonmedical values, to conflate appropriate medical decisions with right moral decisions, and to conceive problems at the bedside in terms of "getting" patients and families to "go along" with the treatment plans of clinicians. In sum, there is within clinical pragmatism the potential for physicians to take back some of the power they ceded to patients during the height of the patients' rights and autonomy movement. Provided that clinicians guard against the temptation to use clinical pragmatism manipulatively, however, the method promises, more than most other methods of moral problem solving, to help increasingly diverse individuals make good moral decisions about patients' care under conditions of enormous uncertainty.     

The Christian physician in the non-Christian institution: objections of conscience and physician value neutrality.

Christian physicians are in danger of losing the right of conscientious objection in situations they deem immoral. The erosion of this right is bolstered by the doctrine of "physician value neutrality" (PVN) which may be an impetus for the push to require physicians to refer for procedures they find immoral. It is only a small step from referral to compelling performance of these same procedures. If no one particular value is more morally correct than any other (a foundational PVN premise) and a physician ought to be value neutral, than conscientious objection to morally objectionable actions becomes a thing of the past. However, the argument for PVN fails. Therefore, Christian physicians should state their values openly, which would allow patients the ability to choose like-minded physicians. Some possible responses to this erosion of conscientious objection include, disengagement from non-Christian institutions, the formation of distinctly Christian medical institutions and political action. However, for the Christian the initial focus should be on a life of holiness which requires each of us to avoid evil.     

What does the character of medicine as a social practice imply for professional conscientious objection?

The dispute over professional conscientious objection presumes a picture of medicine as a practice governed by rules. This rule-based conception of medical practice is identifiable with John Rawls’s conception of social practices. This conception does not capture the character of medical practice as experienced by practitioners, for whom it is a sensibility or “form of life” rather than rules. Moreover, the sensibility of medical practice as experienced by physicians is at best neutral, and at worst hostile, to the demands of those who would override physician conscientious objection to the provision of currently contested services. That being so, calls for overriding physician conscientious objection are much more demanding of the medical profession than they appear in light of Rawls’s view. As such overriding may entail the forcible transformation of medicine’s form of life, the author contends that it would be more prudent to provide contested services by circumventing the medical profession than by compelling it.     

Conventions and Moral Norms: The Legacy of Lewis

David Lewis’ Convention has been a major source of inspiration for philosophers and social scientists alike for the analysis of norms. In this essay, I demonstrate its usefulness for the analysis of some moral norms. At the same time, conventionalism with regards to moral norms has attracted sustained criticism. I discuss three major strands of criticism and propose how these can be met. First, I discuss the criticism that Lewis conventions analyze norms in situations with no conflict of interest, whereas most, if not all, moral norms deal with situations with conflicting interests. This criticism can be answered by showing that conventions can emerge in those contexts as well. Secondly, I discuss the objection that this type of conventionalism, inspired by Lewis, presents moral norms as fundamentally contingent, whereas most, if not all, moral norms are not. However, such critics fail to appreciate that conventions are not radically contingent. Moreover, if one distinguishes the question as to why an individual should comply with a norm from the question whether the norm in question itself can be justified, a core element of the complaint of contingency disappears. The third objection to conventionalism concerns the way in which conventionalists justify norms. I argue that reflection upon the way in which according to Lewis norms are justified reveals a fundamental tension in his theory. Possible solutions to this tension all have in common that the complaint of contingency returns in some form. Therefore, this third complaint cannot be avoided altogether.     

How clinicians make (or avoid) moral judgments of patients: implications of the evidence for relationships and research

Physicians, nurses, and other clinicians readily acknowledge being troubled by encounters with patients who trigger moral judgments. For decades social scientists have noted that moral judgment of patients is pervasive, occurring not only in egregious and criminal cases but also in everyday situations in which appraisals of patients' social worth and culpability are routine. There is scant literature, however, on the actual prevalence and dynamics of moral judgment in healthcare. The indirect evidence available suggests that moral appraisals function via a complex calculus that reflects variation in patient characteristics, clinician characteristics, task, and organizational factors. The full impact of moral judgment on healthcare relationships, patient outcomes, and clinicians' own well-being is yet unknown. The paucity of attention to moral judgment, despite its significance for patient-centered care, communication, empathy, professionalism, healthcare education, stereotyping, and outcome disparities, represents a blind spot that merits explanation and repair. New methodologies in social psychology and neuroscience have yielded models for how moral judgment operates in healthcare and how research in this area should proceed. Clinicians, educators, and researchers would do well to recognize both the legitimate and illegitimate moral appraisals that are apt to occur in healthcare settings.     

Are there dead persons?

Schechtman’s ‘Person Life View’ (PLV) offers an account of personal identity whereby persons are the unified loci of our practical and ethical judgment. PLV also recognises infants and permanent vegetative state patients as being persons. I argue that the way PLV handles these cases yields an unexpected result: the dead also remain persons, contrary to the widely-accepted ‘Termination Thesis.’ Even more surprisingly, this actually counts in PLV’s favor: in light of our social and ethical practices which treat the dead as moral patients, PLV gives a more plausible account of the status of the dead than its rival theories.     

Health care and human rights: against the split duty gambit

There are various grounds on which one may wish to distinguish a right to health care from a right to health. In this article, I review some old grounds before introducing some new grounds. But my central task is to argue that separating a right to health care from a right to health has objectionable consequences. I offer two main objections. The domestic objection is that separating the two rights prevents the state from fulfilling its duty to maximise the health it provides each citizen from its fixed health budget. The international objection is that separating a human right to health care fails the moral requirement that, for any given moral human right, the substance to which any two right-holders are entitled be of an equal standard.     

The Normative Underpinnings of Democracy and the Balance between Morality and Legitimacy

ABSTRACT

Jürgen Habermas’s political philosophy incorporates the view that legitimacy is immanent to law, even though it makes morality a central component of democratic legitimacy. Taking this as a starting point, the article examines one criticism that applies to Habermas’s political theory, insofar as he puts morality at the centre of his reconstruction of the concept of legitimacy. Habermas claims that the moral point of view justifies only those norms that embody universalizable interests and rules out those that embody particular interests. Therefore, the objection is that particular citizens will have no reason to endorse these norms and act according to them because these norms do not incorporate their interests. The article goes on to show that Habermas can successfully answer this objection by means of the principle of discourse. The principle performs this function, inasmuch as it has a post-Kantian nature. On the one hand, it incorporates Kantian autonomy. And on the other, the Hegelian insight that autonomy has to be actualized through modern institutions and practices.     

Referral in the Wake of Conscientious Objection to Abortion

Currently, the preferred accommodation for conscientious objection to abortion in medicine is to allow the objector to refuse to accede to the patient's request so long as the objector refers the patient to a physician who performs abortions. The referral part of this arrangement is controversial, however. Pro‐life advocates claim that referrals make objectors complicit in the performance of acts that they, the objectors, find morally offensive. McLeod argues that the referral requirement is justifiable, although not in the way that people usually assume.     

Moral Hedging and Responding to Reasons

In this paper, I argue that the fetishism objection to moral hedging fails. The objection rests on a reasons‐responsiveness account of moral worth, according to which an action has moral worth only if the agent is responsive to moral reasons. However, by adopting a plausible theory of non‐ideal moral reasons, one can endorse a reasons‐responsiveness account of moral worth while maintaining that moral hedging is sometimes an appropriate response to moral uncertainty. Thus, the theory of moral worth upon which the fetishism objection relies does not, in fact, support that objection.     

Persistent Vegetative State: A Presumption to Treat

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation.     

The Problem of Obligation,the Finite Rational Will,and Kantian Value Realism

Abstract

Robert Stern's Understanding Moral Obligation is a remarkable achievement, representing an original reading of Kant's contribution to modern moral philosophy and the legacy he bequeathed to his later-eighteenth- and early-nineteenth-century successors in the German tradition. On Stern's interpretation, it was not the threat to autonomy posed by value realism, but the threat to autonomy posed by the obligatory nature of morality that led Kant to develop his critical moral theory grounded in the concept of the self-legislating moral agent. Accordingly, Stern contends that Kant was a moral realist of sorts, holding certain substantive views that are best characterized as realist commitments about value. In this paper, I raise two central objections to Stern's reading of Kant. The first objection concerns what Stern identifies as Kant's solution to the problem of moral obligation. Whereas Stern sees the distinction between the infinite will and the finite will as resolving the problem of moral obligation, I argue that this distinction merely explains why moral obligations necessarily take the form of imperatives for us imperfect human beings, but does not solve the deeper problem concerning the obligatory nature of morality—why we should take moral norms to be supremely authoritative laws that override all other norms based on our non-moral interests. The second objection addresses Stern's claim that Kantian autonomy is compatible with value realism. Although this is an idea with which many contemporary readers will be sympathetic, I suggest that the textual evidence actually weighs in favor of constructivism.