Principled Conscientious Provision: Referral Symmetry and Its Implications for Protecting Secular Conscience.

"Conscientious provision" refers to situations in which clinicians wish to provide legal and professionally accepted treatments prohibited within their (usually Catholic) health care institutions. It mirrors "conscientious objection," which refers to situations in which clinicians refuse to provide legal and professionally accepted treatments offered within their (usually secular) health care institutions. Conscientious provision is not protected by law, but conscientious objection is.

Conscientious Objection to Aggressive Interventions for Patients in a Vegetative State.

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.

The Right to Be Childfree.

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.

Philosophical Failure and the Reasonability View of Conscientious Objection: Can Reason Adjudicate Metaphysical or Religious Claims?

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.

Responding to Fiester's Critique of a Bioethical Consensus Project.

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.

An Argument for Standardized Ethical Directives for Secular Healthcare Services.

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.

Non-Roman Catholic Physicians Should Be Permitted to Write Prescriptions for Birth Control in Roman Catholic Institutions.

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.

Three Kinds of Decision-Making Capacity for Refusing Medical Interventions.

According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account-what we call DMC. We describe how patients may possess DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or DMC for refusal if they have an overriding goal that is inconsistent with treatment.

Are conscientious objectors morally obligated to refer?

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.

Secular Clinical Ethicists Should Not Be Neutral Toward All Religious Beliefs: An Argument for a Moral-Metaphysical Proceduralism.

Secular clinical ethics has responded to the problem of moral pluralism with a procedural approach. However, defining this term stirs debate: H. Tristram Engelhardt Jr.

The Baffling Babble of Brain Injury.

This paper presents a dialogue that demonstrates the baffling babble of brain injury, a phenomenon that can occur when physicians' medical in formation is either exceedingly vague or delivered through terminology that can be misinterpreted by surrogates. Brain babble is distinguished from more traditional forms of miscommunication in the clinical context because of the significant degree of clinical uncertainty, existential weight, and the ability to create lose-lose decisions from which clinicians experience moral distress after providing treatments the surrogates never would have requested had they a better understanding of their loved one's neurologic injury. The paper ends with some recommendations for discussing severe brain injury with surrogates.

Should Positive Claims of Conscience Receive the Same Protection as Negative Claims of Conscience? Clarifying the Asymmetry Debate.

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.