Wrongness, Responsibility, and Conscientious Refusals in Health Care

Abstract

In this article, I address what kinds of claims are of the right kind to ground conscientious refusals. Specifically, I investigate what conceptions of moral responsibility and moral wrongness can be permissibly presumed by conscientious objectors. I argue that we must permit HCPs to come to their own subjective conclusions about what they take to be morally wrong and what they take themselves to be morally responsible for. However, these subjective assessments of wrongness and responsibility must be constrained in several important ways: they cannot involve empirical falsehoods, objectionably discriminatory attitudes, or unreasonable normative beliefs. I argue that the sources of these constraints are the basic epistemic, relational, and normative competencies needed to function as a minimally decent health-care professional. Finally, I consider practical implications for my framework, and argue that it shows us that the objection raised by the plaintiffs in Zubik v. Burwell is of the wrong sort.

Conscience absolutism via legislative amendment

“…(8) However, in recent years, the long running debate surrounding conscientious objection in health care has become increasingly heated. (9)(10)(11) This is partly because of the increasing number of cases in which requests for CBEs are made, and partly because of the way in which appeals to freedom of conscience are used in increasingly expansive ways that limit the rights of clients to basic health care services. 1 Equally, the enactment of the Obama Administration's Patient Protection and Affordable Care Act (PPACA) prompted a number of legal challenges to certain provisions of the Act on grounds that they obliged employers and insurers to 1 Follo wing West-Or a m a nd B uyx, we use the ter m "clie nt" to re fer to tho se acc essing hea lth care ser vice s in co nsc ie ntio us objectio n sce nario s, since co nscie nce c la ims ca n also be made b y p har macists and other provider s who do no t have "patie nts" .…”

“…(10) provide insurance coverage for services which some people may believe are immoral. (9)(10)(11)(12) The scope of these various legislative and litigative expansions of the right to conscientiously object in the health care context varies. The British Abortion Act for example offers relatively limited concessions to objectors, while more recent legislation in Mississippi provides extremely broad scope to the range of health care services from which objecting providers may excuse themselves.…”

“…(1,13) This expansion of conscience rights to insurers and employers was also expanded at the American Federal level by the Supreme Court of the United States' (SCOTUS) ruling in Burwell vs. Hobby Lobby et al which found in favour of a group of religious employers who wished to opt out of paying for insurance coverage for certain contraceptives which were mandated by the PPACA. (10,14) Further extensions and expansions at the State and Federal level were made by later lawsuits, (11,12,15) while Texas and Arkansas each enacted legislation further entrenching HCP rights to conscientious objection. (15,16) Importantly, this expansion of the right to conscientious objection is not a uniquely American phenomenon -in the United Kingdom, a Bill aimed at a similar expansion of the rights of health care workers to conscientiously object to participating in the provision of contested services is currently under review in the House of Lords.…”

Conscience and conscientious objection: The midwife’s role in abortion services

“…Widely diverging views have been articulated by Pellegrino 22 who considered freedom of conscience as a moral right and Fiala and Arthur 37 who classified conscientious objection as ‘dishonourable disobedience’ and as ‘unethical refusal to treat’. Furthermore, Liberman 38 stated that conscientious refusals in health care can even be ‘moral wrongness’ and Pellegrino noted, ‘both the physician and the patient as human beings are entitled to respect for their personal autonomy. Neither one is empowered to override the other.…”

“…His view of conscientious objection to abortion in medicine proposed that abortion might be immoral for one person while it might be morally permissible for another stating:Both ought humbly to acknowledge the fallibility of their positions and their inability to persuade each other of the truth of these positions, but this need not mean that one must conclude that neither position is true or that moral truth is subjective.Widely diverging views have been articulated by Pellegrino 22 who considered freedom of conscience as a moral right and Fiala and Arthur 37 who classified conscientious objection as ‘dishonourable disobedience’ and as ‘unethical refusal to treat’. Furthermore, Liberman 38 stated that conscientious refusals in health care can even be ‘moral wrongness’ and Pellegrino noted, ‘both the physician and the patient as human beings are entitled to respect for their personal autonomy. Neither one is empowered to override the other.…”