Abram Brummett

Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of “futility”, but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment.

This article reports results of a survey about employment and compensation models for clinical ethics consultants working in the United States and discusses the relevance of these results for the professionalization of clinical ethics. This project uses self-reported data from healthcare ethics consultants to estimate compensation across different employment models. The average full-time annualized salary of respondents with a clinical doctorate is $188,310.08 (SD=$88,556.67), $146,134.85 (SD=$55,485.63) for those with a non-clinical doctorate, and $113,625.00 (SD=$35,872.96) for those with a masters as their highest degree. Pay differences across degree level and type were statistically significant (F = 3.43; p.

Abstract:In this manuscript, we start with a real life account of an Ob/Gyn experience with a young patient from the childfree movement requesting permanent sterilization. A narrative ethics approach invites the reader to experience the encounter in an immersive way for this growing issue. This approach allows readers to reflect on their reaction to the patient and consider how that can affect other patient encounters. Additionally, it explores the stigma these young patients encounter making a permanent decision to never have children. In the commentary, we explore the ethical issues in this case including why we question the permanent decision to refrain from having children. We also discuss informed consent and patient education along with the various approaches to physician-patient relationships with an emphasis on shared decision making, which allows space for both patient and physician to question and reason through their health decisions.

The legal and ethical asymmetry between honoring positive claims of conscience versus negative claims of conscience was recently analyzed by several articles in this journal. The first author of this article (ALB) identified unique but defeasible reasons against honoring positive claims of conscience, such as the greater threat they post to institutional values and institutional resources than negative claims of conscience. However, ALB wrote, when these reasons can be overcome, positive claims of conscience should enjoy the same ethical and legal respect as negative claims of conscience. This article argues that the prescription of birth control by non-Roman Catholic physicians in Roman Catholic institutions is an example of a positive claim of conscience that can overcome concerns of institutional values and resources, and therefore ought to receive the same ethical respect and legal protection as negative claims of conscience. In making this argument, this article also responds to several of the thoughtful comments raised by Alberto Giubilini and Dominic Wilkinson.

We argue that the American Society for Bioethics and Humanities has endorsed a facilitation approach to clinical ethics consultation that asserts that bioethicists can offer moral recommendations that are well-grounded in bioethical consensus. We claim that the closest thing the field currently has to a citable, nationally endorsed bioethical consensus are the 22 Core References used to construct the questions for the Healthcare Ethics Consultant-Certified (HEC-C) exam. We acknowledge that the Core References reflect some important points of bioethical consensus, but note they are unwieldy, repetitive, and sometimes inconsistent on important issues faced by clinical ethicists. In this article, we draw carefully qualified inspiration from the Ethical and Religious Directives for Catholic Health Care Services (ERDs) to argue for the creation of a concise, nationally endorsed bioethical consensus document on moral issues commonly faced in clinical ethics, what we call the Standardized Ethical Guidelines for Secular Health Care Services (SEGs). We observe that such a document would better meet the expectations of stakeholders, clinical ethicists, and their trainees who desire moral recommendations grounded in a clearly articulated bioethical consensus, and we defend the SEGs from some common objections.

We respond to Autumn Fiester’s critique that our proposed bioethical consensus project amounts to “ethical hegemony,” and evaluate her claim that ethicists should restrict themselves to “mere process” recommendations. We argue that content recommendations are an inescapable aspect of clinical ethics consultation, and our primary concern is that, without standardization of bioethical consensus, our field will vacillate among appeals to the disparate claims in the 22 “Core References,” unsustainable efforts to defend value-neutral process recommendations, or become a practice of Lone Ranger clinical ethicists. We contend that a consensus document that captures the basic moral commitments of patients and careproviders is the next step in the professional evolution of our field.

In the debate over clinicians’ conscience, there is a greater ethical, legal, and scholarly focus on negative, rather than positive, claims of conscience. This asymmetry produces a seemingly unjustified double standard with respect to clinicians’ conscience under the law. For example, a Roman Catholic physician working at a secular institution may refuse to provide physician-aid-in-dying on the basis of conscience, but a secular physician working at a Roman Catholic institution may not insist on providing physician-aid-in-dying on the basis of conscience. This article outlines arguments against this asymmetry and critiques them for failing to distinguish between positive claims of conscience as positive or negative rights. I suggest the asymmetry debate should be focused on whether positive claims of conscience as positive rights ought to enjoy the same protections as negative claims of conscience. Clarifying the debate in this way helps elucidate some of the best reasons for the asymmetry, which these arguments have not addressed. This article does not take a definitive position on whether the asymmetry is justified, but attempts to bring some focus to the debate by directing arguments against the asymmetry to address the significant differences between positive claims of conscience as positive rights and negative claims of conscience.

Legal precedent, professional‐society statements, and even many medical ethicists agree that some situations may call for a clinician to engage in an act of lying or nonlying deception of a patient or patient's family member. Still, the moral terrain of clinical deception is largely uncharted, and when it comes to practical guidance for clinicians, many might think that ethicists offer nothing more than the rule never to deceive. This guidance is insufficient to meet the real‐world demands of clinical practice, and this article endeavors to articulate a framework to help clinicians better navigate the ethics of clinical deceit. The framework articulates four morally relevant dimensions of a potential deceptive act that should be examined to better determine the moral justification that might be required: the target of the act, the nature of the information, the nature of the act, and the context of the act.

While many Catholic hospitals permit the prescription of the emergency contraception drug levonorgestrel for rape victims, some continue to prohibit this practice as a matter of institutional conscience. While the standard approach to this issue has been to offer an argument that levonorgestrel either is or is not morally permissible, we have taken a different tack. We begin by briefly describing and acknowledging that reasonable disagreement exists on this question (part one), and then arguing that the reasonable disagreement itself can serve as a compelling basis for Catholic leadership at hospitals that prohibit emergency contraception for rape victims to accommodate physicians who wish to provide levonorgestrel as a matter of conscience (part two). We end by anticipating and responding to some objections.

Given recent legal developments in the United States, now is a critical time to draw attention to how ‘conscientious objection’ is sometimes used by health care providers to discriminate against the LGBTQ community. We review legal developments from 2019 and present several cases where health care providers used conscientious objection in ways that discriminate against the LGBTQ community, resulting in damaged trust by this underserved population. We then discuss two important conceptual points in this debate. The first involves the interpretation of discrimination (provider versus patient-centered views), and we argue for a patient-centered view; the second involves the use of the people versus procedure distinction to reach a compromise between LGBTQ individuals and the clinicians who do not want to treat them. We argue the distinction is problematic when applied to treatment of the LGBTQ population.

The legal and ethical asymmetry between honoring positive claims of conscience versus negative claims of conscience was recently analyzed by several articles in this journal. The first author of this article (ALB) identified unique but defeasible reasons against honoring positive claims of conscience, such as the greater threat they post to institutional values and institutional resources than negative claims of conscience. However, ALB wrote, when these reasons can be overcome, positive claims of conscience should enjoy the same ethical and legal respect as negative claims of conscience. This article argues that the prescription of birth control by non-Roman Catholic physicians in Roman Catholic institutions is an example of a positive claim of conscience that can overcome concerns of institutional values and resources, and therefore ought to receive the same ethical respect and legal protection as negative claims of conscience. In making this argument, this article also responds to several of the thoughtful comments raised by Alberto Giubilini and Dominic Wilkinson.

Tiffany was seventeen when injury to her brain stem put her in the intensive care unit on life‐sustaining treatment and in a permanently locked‐in state—fully conscious but able to control no bodily movements other than her eye movements. As a clinical ethicist at the hospital, I was consulted by her neurologist, who had established a blink‐once‐for‐yes, twice‐for‐no system of communication so that Tiffany could respond to questions. Her mother wanted Tiffany to continue receiving treatment that could prolong her life for years, potentially decades. In a meeting with the neurologist and family, I felt like suggesting what nobody seemed willing to suggest: that we should ask Tiffany what she wants.

Robert Card has proposed a reasonability view of conscientious objection that asks providers to state the reasons for their objection for evaluation and approval by a review board. Jason Marsh has challenged Card to provide explicit criteria for what makes a conscientious objection reasonable, which he claims will be too difficult a task given that such objections often involve contentious metaphysical or religious claims. Card has responded by outlining standards by which a conscientious objection could be judged reasonable. In this paper, I extend Marsh’s critique to key concepts in the standards outlined by Card such as abortifacient, harm, emergency, and discrimination, showing they can be given radically different interpretations given different metaphysical or religious presumptions. To resolve these conflicting interpretations, a reasonability view of conscientious objection will need more than the criteria outlined by Card, it will need the resources to evaluate the reasonability of metaphysical or religious claims.

In the debate over clinicians’ conscience, there is a greater ethical, legal, and scholarly focus on negative, rather than positive, claims of conscience. This asymmetry produces a seemingly unjustified double standard with respect to clinicians’ conscience under the law. For example, a Roman Catholic physician working at a secular institution may refuse to provide physician-aid-in-dying on the basis of conscience, but a secular physician working at a Roman Catholic institution may not insist on providing physician-aid-in-dying on the basis of conscience. This article outlines arguments against this asymmetry and critiques them for failing to distinguish between positive claims of conscience as positive or negative rights. I suggest the asymmetry debate should be focused on whether positive claims of conscience as positive rights ought to enjoy the same protections as negative claims of conscience. Clarifying the debate in this way helps elucidate some of the best reasons for the asymmetry, which these arguments have not addressed. This article does not take a definitive position on whether the asymmetry is justified, but attempts to bring some focus to the debate by directing arguments against the asymmetry to address the significant differences between positive claims of conscience as positive rights and negative claims of conscience.

We describe a case of parents refusing a tracheostomy for an otherwise healthy newborn. The refusal was not honored because permitting the refusal would have violated state law, which required a child to have a qualifying condition (e.g. a terminal diagnosis, permanent unconsciousness, incurable condition with severe suffering) to remove or withhold life-sustaining treatment. However, this case strained the relationship between the parents and medical staff, who worried about sending the newborn home with a tracheostomy where she was not wanted. While many ethical issues arise in treatment refusal cases like this, we focus on the opportunity for ethicists to help the medical staff reflect on the technological alienation of the parents, which may help foster empathy, reduce moral distress, and strengthen the quality of the doctor-parent-patient triad.

In this paper, we argue that providers who conscientiously refuse to provide legal and professionally accepted medical care are not always morally required to refer their patients to willing providers. Indeed, we will argue that refusing to refer is morally admirable in certain instances. In making the case, we show that belief in a sweeping moral duty to refer depends on an implicit assumption that the procedures sanctioned by legal and professional norms are ethically permissible. Focusing on examples of female genital cutting, clitoridectomy and ‘normalizing’ surgery for children with intersex traits, we argue that this assumption is untenable and that providers are not morally required to refer when refusing to perform genuinely unethical procedures. The fact that acceptance of our thesis would force us to face the challenge of distinguishing between ethical and unethical medical practices is a virtue. This is the central task of medical ethics, and we must confront it rather than evade it. There are no data in this work.

Since the inception of bioethics, some theorists have denied that clinical ethicists have ethics expertise, understood as the ability to give justified moral recommendations in patient cases. These denials have caused considerable alarm, leading some to argue that the entire discipline needs to be fundamentally reconsidered. Although this debate has been a source of academic attention for decades, these challenges to ethics expertise can now be either resolved by showing they are based on an untenable view of moral justification or dissolved by showing they result from a rash of equivocations on key phrases such as what it means to give a “moral recommendation,” or “furnish answers” in an ethics consultation. Like the blind men and the elephant, what sounds like disagreement may only be theorists describing different aspects of the same facilitation approach to clinical ethics endorsed by the American Society for Bioethics and Humanities. While the question of whether ethicists have ethics expertise can be resolved or dissolved, theorists should refocus on how much (content-thick vs. content-thin) expertise ethicists have. Here, theorists need not commit themselves to a general view but can be content-thick on some issues and content-thin on others.

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities endorse an “ethics facilitation” approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making, which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for presuming contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt’s solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt’s negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise—defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities—from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt’s critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt’s view is an unstable basis for that worry.