Conscientious Objection

Conscientious Objection Do Nurses Have the Right to Refuse to Provide Care? Renece Waller-Wise, CNS, MSN, CLC, LCCE

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Clinical Application

The professional dilemma becomes how to maintain adherence to personal mores and conscience and at the same time carry out the duty to the patient without the appearance of abandonment

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Consider Betty—a part-time labor and delivery nurse who has been with her present employer for six months. Betty is the wife of a minister whose church’s official position on abortion is that it’s only condoned in cases of a threat to the mother’s life. Also of interest is that Betty has an eightmonth-old nephew who has Trisomy 18. During the pre-employment interview, the department manager of labor and delivery informed Betty of issues of potential conflict to any moral, ethical or religious view that Betty might hold. Specifically, Betty was informed that within the scope of care of the labor and delivery unit there may be times when blood transfusions are given and that family planning interventions including permanent sterilization and birth control education might be given. Betty was also told that although elective ter-

minations of pregnancy did not take place within the facility, there may be times when terminations for lethal anomalies did. During this pre-employment interview Betty expressed her view that while she had no objection to administering blood transfusions or providing family planning interventions, she would not participate in pregnancy terminations, unless they were to preserve the life of the mother. Betty distinctly sited both her religious views and her love for her nephew as reasons behind her refusal to provide this type of care. At the

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end of this interview the manager offered Betty the part-time position for which she was interviewing, and Betty accepted the position. In the course of orientation to her new job, Betty was informed that there was a hospital policy that allowed for Betty to object to aspects of providing care on religious or moral grounds. Betty completed the required forms and gave these forms to the labor and delivery department manager, as the hospital policy described. In turn the labor and delivery manager met with Betty to discuss the accommodations that were to be made. The department manager disclosed Betty’s objections to the shift charge nurses, and it was decided that since there was ample staffing in labor and delivery for most shifts that Betty would not be assigned to patients undergoing termination for a lethal anomaly. Betty was very pleased to discover that in fact when a patient presented for termination for anencephaly she was not assigned to care for that patient. To date, the arrangement continues to work well for Betty, her colleagues and her employer. There has been much written about the patient’s right to receive nursing care that is free from discrimination based on race, color, religion, sex and national origin (American Nurses Association, 1997). Yet an issue that is less often discussed is a nurse’s right to provide care that does not violate her own personal beliefs. Do nurses have the right to refuse to provide care when doing so goes against their own ethics or morals?

Exploring Normative Ethics In health care, conscientious objection can be defined as the refusal of any member of the health care team to take part in some aspect of care for a patient on the basis of conscience (Dickens, 2001). Conscience denotes a deliberate attentiveness to the morality of an action and the temperament to be attentive to that action. Conscience has three particular characteristics (Baker, 1996): Renece Waller-Wise, CNS, MSN, CLC, LCCE, is a licensed perinatal clinical nurse specialist at Southeast Alabama Medical Center in Dothan, AL. DOI: 10.1177/1091592305280872

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• an internal sense of responsibility that influences judgments regarding right and wrong actions • the consequence of internalization of norms and mores of the culture • a representation of the uprightness and totality of the person

Fundamentally, regard for nurses’ personal and conscientiously held values is tantamount to regard for human worth and dignity (Weber & Bissel, 2001). Decisions involving conscience have their roots in normative ethics. Normative ethics are those grassroots moral philosophies, norms or values that are used when deciding an action. Normative ethics guide decisions regarding what is right and wrong. Normative ethics also influence interpretation of our rights involving the actions to take. Normative ethics and conscience guide health care providers, including nurses, in decision making (Baker, 1996). There are many ethical issues that shroud decision making in today’s health care arena. These issues provide a challenge to both providers and recipients of care (Baker, 1996). Some of the issues that evoke conflicts in cultural values, ethics or religious beliefs are as follows (Davino, 1996): • administration of blood and/or blood products • termination of pregnancy procedures • termination of life support • assisted suicide • cessation of feeding • organ/tissue donation and transplantation • contraception and/or family planning interventions including permanent sterilization, birth control education and emergency contraception In health care, patients have the right to refuse care. For example, health care providers are aware that persons who are practicing Jehovah’s Witnesses will likely refuse blood products. Virtually every hospital has a policy to follow to allow for this exclusion of care, but what of the rights of a health care provider who is a practicing Jehovah’s Witness with regard to procedures involving blood products? Does such a provider have a right to refuse to give blood? Likewise, in maternal-infant nursing what are the nurse’s rights to refuse to assist with a pregnancy termination? What are the rights of the Catholic nurse who refuses to teach about emergency contraceptives? Personal religious, ethical or moral beliefs place health care providers in an awkward position. The professional dilemma becomes how to maintain adherence to personal mores

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and conscience and at the same time carry out the duty to the patient without the appearance of abandonment (Ventura, 1999). The nurse who objects to certain aspects of care may be labeled as a menace, troublemaker or a rabble-rouser by co-workers and supervisors (Baker, 1996). Therefore, careful attention to attitudes, ethics and legalities involved is imperative.

Legalities and Standards The legal standard for refusal to give care for religious, ethical or moral reasons in the U.S. is not covered under a single law. Instead there are several laws and regulations that impact or control the provision of religious beliefs effects in the place of work. Overall, these statutes support an individualistic view of religious tenets (Society for Human Resource Management, 2001). Freedom from employment discrimination based on race, color, religion, sex and national origin is protected under Title VII of the Civil Rights Act of 1964. Under this statute, employers are mandated to ensure reasonable accommodations for the religious practices of an employee or prospective employee unless to do so would create an undue encumbrance, though difficulty arises in defining what is reasonable (Davino, 1996; Horsley, 1992; Society for Human

Resource Management, 2001; Ventura, 1999). Specifically Title VII states that an employer may not discriminate against an employee because of the presence or absence of religious practice. Finally, employers are mandated to provide a workplace environment that is free from religious harassment in the same manner as it’s free from sexual harassment (Lindsay & Bach, 1999). The Clinton Administration reinforced this with the release of the “Guidelines on Religious Expression and Exercise in the Federal Workplace” (Society for Human Resource Management, 2001). Additionally there are at least 44 states that have laws that shield health care personnel from retaliation for refusing to provide some aspects of care (Davino, 1996). The American Nurses Association has set a precedent for a nurse’s refusal to provide care in their position statement “The Right to Accept or Reject an Assignment” (American Nurses Association, 1997). The American Nurses Association also addresses the issue in its “Code for Nurses With Interpretive Statements” (Ventura, 1999). Likewise the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognizes the nurse’s right to refuse to provide certain aspects of care (JCAHO, 2000; see Table 1). JCAHO has added standards to its hospital and home health accreditation

Table 1.

manuals that are meant to address the issues of cultural, religious or ethical conflicts. Hospital facilities must have policies that delineate the specific aspects of care that may conflict with an employee’s personal religious, moral or ethical values and beliefs. The hospital must have a written policy that allows for the exclusion of certain aspects of care. Institutions must have a process by which requests for exclusion from care are reviewed, and in situations where employees are excused from providing care, there must be a plan to maintain quality care in the employee’s absence (JCAHO, 2000). The JCAHO standards further state that the employee should be informed during the pre-employment process of potential conflicts in providing care. It also states that when the employee is notified during the orientation process that the employee may be excused from certain aspects of care that interfere with the cultural values, ethics or religious beliefs of the employee, if the employee identifies those aspects of care in writing. Furthermore, supervisors should review the requests for exclusion from care to determine if “reasonable accommodation” can be made. If accommodation is made, those involved should be informed; if accommodation is not possible, the employee should be counseled as to other options of employment. Finally, the standards state that during emergency situations the employee will be required to provide care despite cultural, religious or ethical beliefs (JCAHO, 2000; Oak, 1996).

JCAHO Standards HR.6

The hospital addresses a staff member’s request not to participate in any aspect of patient care

HR.6.1

The hospital ensures that a patient’s care will not be negatively affected if the hospital grants a staff member’s request not to participate in an aspect of patient care

HR6.2

Policies and procedures specify those aspects of patient care that might conflict with staff members’ cultural values or religious beliefs

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Nurses’ Responsibilities Nurses must state their objections to providing care well in advance of a conflicting situation. In one case that made its way into the judicial system, the court questioned a nurse’s refusal of care because it came only hours before the procedure. Specifically a nurse anesthetist refused to participate

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in a tubal ligation stating that she did so for moral, religious reasons (Swanson v. St. John’s Luehrs Hospital, 1979). Nurses should also be aware that once they begin treating a patient they are legally bound to continue until the patient has been reassigned to another nurse, or else they risk charges of abandonment (Davino, 1996; Ventura, 1999). Therefore, it behooves the nurse to make objections well known prior to the situation arising. Nurses must also be perfectly clear as to the reason for refusal. Hospital policies typically require that the refusal be made on the basis of moral, ethical or religious grounds. Nurses cannot simply refuse because they do not want to be involved in the case (Davino, 1996; Ventura, 1999). A clear distinction should be made between refusal to perform a type of procedure or treatment and not simply a refusal to care for a patient (Weber & Bissel, 2001). Nurses should also be consistent in their refusal of care. Nurses cannot refuse to provide care today for one patient, and then tomorrow care for the next patient with a similar case (Dickens & Cook, 2000; Weber & Bissel, 2001).

Employer’s Responsibilities Once the nurse has formally stated an objection to care, then the employer’s responsibility begins. The employer then must attempt to make reasonable accommodations. The employer must

Box 1.

Getting All the Facts • American Nurses Association: www.nursingworld.org • Joint Commission on Accreditation of Healthcare Organizations: www.jcaho.org • Society for Human Resource Management: www.shrm.org

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take into consideration the type of care the employee has asked to be excused from, and whether or not this activity is fundamental to the employee’s job function. Patient care should not suffer, and simultaneously coworkers should not be unreasonably inconvenienced with the accommodations (Weber & Bissel, 2001). Yet at the same time courts have been unsympathetic to employers who make no effort to accommodate the employee’s request (Lindsay & Bach, 1999). These accommodations may simply take the form of rearranged assignments or rearranged work schedules. Simple reassignment of patients may be the answer. On the other hand, reassignment to other units of the hospital may be the suggested solution, especially if the particular aspect of care is fundamental to the unit. However, in some instances reassignment may not be the answer at all. Dismissal may be the final answer if the principal undertaking of the unit’s care is one that the nurse cannot carry out. For example, a nurse who refuses to participate in abortions would be ill advised to accept a job in an abortion clinic (Horsley, 1992). After all, nurses do have rights to refuse certain aspects of care. There are often instances when in the care of women and newborns that a nurse’s views of conscience may be tested. The law protects these nurse’s rights. However, nurses must diligently follow the proper steps to declare an objection based on conscience to ensure that charges of patient abandonment are not found (see Box 1). References American Nurses Association. (1997). Position statements: The right to accept or reject an assignment. Kansas City, MO: Author. Baker, T. P. H. (1996). Descriptive and normative ethics: Conscientious objection. Nursing Management, 27(10), 32DD-32FF.

Davino, M. (1996). You don’t have to care for every patient. RN, 59(9), 63-67. Dickens, B. M. (2001). Reproductive health services and the law and ethics of conscientious objection. Medicine and Law, 20(2), 283-293. Dickens, B. M., & Cook, R. J. (2000). The scope and limits of conscientious objection. International Journal of Gynecology and Obstetrics, 71(1), 71-77. Horsley, J. (1992). Abortion and nursing: A legal update. RN, 55(12), 57-58. Joint Commission on Accreditation of Healthcare Organizations. (2000, May). Standards, intents, and examples for managing staff requests. In Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: Author. Lindsay, R. A., & Bach, E. H. (1999, April). Prohibiting discrimination based on religion: An employer’s obligation. In Society for Human Resource Management white paper. Retrieved October 5, 2001, from http://my.shrm.org/whitepapers/ documents/default.asp?page= 61214.asp Oak, J. C. (1996). A conflict of loyalties: Nursing, conscientious objection, and JCAHO HR 5. Making the Rounds in Health, Faith and Ethics, 1(12), 1, 3-5, 8. Society for Human Resource Management. (2001). Legislation and regulations. Retrieved October 4, 2001, from http://my.shrm.org/diversity/ religion/default.asp?page=legreg .asp Swanson v. St. John’s Luehrs Hospital, 597 P.2d. 702, 1979. Ventura, M. J. (1999). Where nurses stand on abortion. RN, 62(3), 44-47. Weber, L., & Bissel, M. G. (2001). Employee conscientious objection. Clinical Leadership and Management Review, 15(2), 114-115.

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