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Adjudicating rights or analyzing interests: ethicists’ role in the debate over conscience in clinical practice

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Abstract

The analysis of a dispute can focus on either interests, rights, or power. Commentators often frame the conflict over conscience in clinical practice as a dispute between a patient’s right to legally available medical treatment and a clinician’s right to refuse to provide interventions the clinician finds morally objectionable. Multiple sources of unresolvable moral disagreement make resolution in these terms unlikely. One should instead focus on the parties’ interests and the different ways in which the health care delivery system can accommodate them. In the specific case of pharmacists refusing to dispense emergency contraception, alternative systems such as advanced prescription, pharmacist provision, and over-the-counter sales may better reconcile the client’s interest in preventing unintended pregnancy and the pharmacist’s interest in not contravening his or her conscience. Within such an analysis, the ethicist’s role becomes identifying and clarifying the parties’ morally relevant interests.

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Notes

  1. Women can use several drugs or devices after un- or under-protected intercourse to prevent unintended pregnancy. Under-protected intercourse includes when a condom slips or breaks or a woman misses two or more of the first seven oral contraceptive pills. I will focus on the use of oral contraceptive pills or pharmacologically equivalent dedicated products for this purpose. Women can also use copper-containing intrauterine devices (IUDs) for emergency contraception but this is more logistically difficult because a trained provider must place them. I will also not discuss the use of mifepristone (RU-486) because, unlike oral contraceptive pills, it can interrupt an established pregnancy and, at higher doses, can cause a medical abortion. The Food and Drug Administration has also not approved its lower, emergency contraceptive dose [3].

    The literature also refers to emergency contraception as postcoital contraception and the morning after pill. Experts criticize the term morning after pill as misleading individuals to believe treatment must wait until or is ineffective after the next morning and prefer the term emergency contraception, in part, because it conveys that it is not intended for ongoing use [4, p. 44].

  2. For news reports of similar cases, see [1, 5].

  3. Commentators should carefully distinguish differences about the scope of morality from disagreements about the facts. Some advocates of access to emergency contraception, for example, argue that it is not abortifacient because it does not prevent the interruption of an established pregnancy. They cite definitions of pregnancy and abortion offered by medical organizations and the U.S. government [17, p. 847]. This is a terminological disagreement based on differing evaluations of the moral status of the embryo rather than a dispute regarding the facts. Groups that consider some or all uses of emergency contraception to be immoral do not contend that it causes the expulsion of a fertilized egg after implantation. Rather, they believe that the fertilized egg has full moral status and use the term abortifacient to include drugs and devices that prevent implantation.

  4. Other alternatives include educational initiatives and public awareness campaigns, information and referral hotlines [23], and telephone prescription services [24].

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Acknowledgements

I would especially like to thank Lainie Freidman Ross for her encouragement; the Conscience in Clinical Practice organizers and participants; and Tess Jones, Michelle Hawes, Grace Chung, Ryan Lawrence, and Farr Curlin for their constructive criticisms of this manuscript.

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  1. Divisions of Pediatric Inpatient Medicine and of Medical Ethics and Humanities, University of Utah School of Medicine, 100 N Mario Capecchi Drive, Salt Lake City, UT, 84113, USA

    Armand H. Matheny Antommaria

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Correspondence to Armand H. Matheny Antommaria.

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Antommaria, A.H.M. Adjudicating rights or analyzing interests: ethicists’ role in the debate over conscience in clinical practice. Theor Med Bioeth 29, 201–212 (2008). https://doi.org/10.1007/s11017-008-9077-x

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