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Conscientious Non-objection in Intensive Care

Abstract:
Abstract:

Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Notes

1. Chow S, Chow R, Popovic M, Lam M, Popovic M, Merrick J, et al. A selected review of the mortality rates of neonatal intensive care units. Frontiers in Public Health 2015;3:225.

2. Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, et al. End-of-life practices in European intensive care units: The Ethicus Study. JAMA 2003;290(6):790–7; Fontana MS, Farrell C, Gauvin F, Lacroix J, Janvier A. Modes of death in pediatrics: differences in the ethical approach in neonatal and pediatric patients. Journal of Pediatrics 2013;162(6):1107–11.

3. Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinova K, Lafabrie A, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. American Journal of Respiratory and Critical Care Medicine 2009;180(9):853–60.

4. Tapper EB, Vercler CJ, Cruze D, Sexson W. Ethics consultation at a large urban public teaching hospital. Mayo Clinic Proceedings 2010;85(5):433–8.

5. See note 3, Azoulay et al. 2009.

6. See note 3, Azoulay et al. 2009.

7. Piers RD, Azoulay E, Ricou B, Dekeyser Ganz F, Decruyenaere J, Max A, et al. Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA 2011;306(24):2694–703.

8. See note 7, Piers et al. 2011.

9. Catlin A, Armigo C, Volat D, Vale E, Hadley MA, Gong W, et al. Conscientious objection: A potential neonatal nursing response to care orders that cause suffering at the end of life? Study of a concept. Neonatal Network 2008;27(2):101–8.

10. See note 9, Catlin et al. 2008.

11. Wilkinson DJ, Truog RD. The luck of the draw: Physician-related variability in end-of-life decision-making in intensive care. Intensive Care Medicine 2013;39(6):1128–32.

12. Garrouste-Orgeas M, Tabah A, Vesin A, Philippart F, Kpodji A, Bruel C, et al. The ETHICA study (part II): Simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over. Intensive Care Medicine 2013;39(9):1574–83.

13. Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: A systematic review. Intensive Care Medicine 2015;41:1572–85.

14. Garland A, Connors AF. Physicians’ influence over decisions to forego life support. Journal of Palliative Medicine 2007;10(6):1298–305.

15. Lewis-Newby M, Wicclair M, Pope T, Rushton C, Curlin F, Diekema D, et al. An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine. American Journal of Respiratory and Critical Care Medicine 2015;191(2):219–27.

16. This definition has some overlap with one provided by Mark Wicclair. (See Wicclair MR. Conscientious Objection in Health Care: An Ethical Analysis. Cambridge: Cambridge University Press; 2011, at.1–4).Wicclair notes two necessary components: (1) a refusal by a health professional to perform or provide a legally and professionally accepted good or service, and (2) that the individual justifies refusal on the basis of core moral beliefs. COs are possible in other areas of life, (for example objections to military service) but are beyond the scope of this article. I have restricted the scope of CO here to courses of treatment requested by or on behalf of the patient. This excludes questions about CO to physician involvement in torture or capital punishment (neither of which are relevant in intensive care).

17. See note 7, Piers et al. 2011.

18. Jotkowitz A, Glick S, Zivotofsky AZ. The case of Samuel Golubchuk and the right to live. American Journal of Bioethics 2010;10(3):50–3.

19. Winnipeg Free Press. Winnipeg hospitals divert key resources to care for dying man. Canada.com June 20, 2008; available at http://www.canada.com/topics/news/national/story.html?id=9c5d6629-64f2-4b57-86fc-496be65c2664 (last accessed 19 Jan 2016). In this case there was a reported religious motivation for the request for treatment, but no religious reason was apparent for the clinicians who were conscientiously objecting.

20. See note 16, Wicclair 2011, at 7–8.

21. See note 11, Wilkinson, Truog 2013.

22. See note 15, Lewis-Newby et al. 2015. Case 3 in the American Thoracic Society document (at 223) represents an example of controversial provision of treatment.

23. Wicclair MR. Conscientious objection in medicine. Bioethics 2000;14(3):205–27, at 207. Case 4 in in the American Thoracic Society document (at 223) also represents an example of this kind.

24. Bulow HH, Sprung CL, Baras M, Carmel S, Svantesson M, Benbenishty J, et al. Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. Intensive Care Medicine 2012;38(7):1126–33.

25. Curlin FA, Nwodim C, Vance JL, Chin MH, Lantos JD. To die, to sleep: US physicians’ religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support. American Journal of Hospice and Palliative Care 2008;25(2):112–20.

26. Dyer C. We felt we had killed him. The Guardian March 13, 2002; available at http://www.theguardian.com/society/2002/mar/13/health.law (last accessed 20 Jan 2016)

27. See note 26, Dyer 2002.

28. White DB, Brody B. Would accommodating some conscientious objections by physicians promote quality in medical care? JAMA 2011;305(17):1804–5.

29. See note 15, Lewis-Newby et al. 2015.

30. I am grateful to an anonymous reviewer for this point.

31. Edwards MJ, Tolle SW. Disconnecting a ventilator at the request of a patient who knows he will then die: The doctor’s anguish. Annals of Internal Medicine 1992;117(3):254–6.

32. See note 26, Dyer 2002.

33. Paris JJ. Autonomy does not confer sovereignty on the patient: A commentary on the Golubchuk case. American Journal of Bioethics 2010;10(3):54–6.

34. See note 11 Wilkinson, Truog 2013.

35. Wilkinson D, Truog R, Savulescu J. In favour of medical dissensus: Why we should agree to disagree about end-of-life decisions. Bioethics 2016;30(2):109–8.

36. Lockhart T. Moral Uncertainty and Its Consequences. New York, Oxford: Oxford University Press; 2000.

37. Although moral uncertainty suggests that an individual clinician should decide not to object, it also plausibly means that society should permit or accommodate objection.

38. See note 35, Wilkinson et al. 2015.

39. Magelssen M. When should conscientious objection be accepted? Journal of Medical Ethics 2012;38(1):1821.

40. I do not have any empirical data here to quantify this burden. My personal experience, however, is that providing high quality care at the end of life involves a substantial commitment of time on the part of senior medical staff as well as nursing staff. This includes time spent with the patient and with the family discussing treatment options and coming to a decision to limit treatment, as well as subsequently ensuring that their needs are addressed. In practice, such patients can require far more intensive personal involvement than other patients in intensive care, with significant physical and emotional consequences for professionals. See Kirby E, Broom A, Good P. The role and significance of nurses in managing transitions to palliative care: a qualitative study. BMJ Open 2014;4(9):e006026; Lee KJ, Dupree CY. Staff experiences with end-of-life care in the pediatric intensive care unit. Journal of Palliative Medicine 2008;11(7):986–90.

41. See note 39, Magelssen 2012.

42. Mobley MJ, Rady MY, Verheijde JL, Patel B, Larson JS. The relationship between moral distress and perception of futile care in the critical care unit. Intensive and Critical Care Nursing 2007;23(5):256–63.

43. Christensen D. Disagreement as evidence: The epistemology of controversy. Philosophy Compass 2009;4(5):756–67.

44. Quinn P. On religious diversity and tolerance. Daedalus 2005;134(1):136–9.

45. Alston W. Religious diversity and perceptual knowledge of God. Faith and Philosophy 1988;5(4):433–48.

46. Wilkinson DJC, Savulescu J. Knowing when to stop: Futility in the ICU. Current Opinion in Anesthesiology 2011;24(2):160–5.

47. Daniels N. Justice, health, and healthcare. American Journal of Bioethics 2001;1(2):216.

48. Savulescu J. Conscientious objection in medicine. BMJ 2006;332(7536):294–7.

A version of this article was presented at the Conscientious Objection in Medicine conference, Oxford, November 2015. I am grateful to participants in the conference for helpful comments.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
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