Healthcare workers are often challenged by situations in which their personal morals are at odds with the care requested or required by a patient. For clinicians in a critical care setting, where patients may be unconscious or close to death, these ethical challenges can be especially overwhelming. Last month, the American Thoracic Society’s Ethics and Conflict of Interest Committee published a new set of guidelines to help medical systems support clinicians’ moral integrity, entitled “Managing Conscientious Objections in Intensive Care Medicine .”
Our own Cynda Hylton Rushton , PhD, RN, FAAN, was part of the multidisciplinary working group that developed the new policy over the course of the past three years. Below, she answers our questions about the project and its importance for clinicians and patients.
- What’s new or different about these guidelines?
These guidelines offer clinicians, administrators and policymakers an ethical analysis of conscientious objection in critical care settings, recommendations for managing them, and components of a model policy for managing conscientious objections in the ICU.
- What made the American Thoracic Society prioritize conscientious objection in intensive care?
Situations that challenge the integrity of clinicians who provide care in the ICU setting are becoming more commonplace. There was no consensus or guidance about how to handle claims of conscientious objection in the ICU setting.
- What kinds of conscientious objections do you hear about from critical care clinicians? As a nurse, have you seen coworkers face many challenges to their moral integrity?
There are situations where clinicians may have moral objections to providing or disclosing information about a medical service such as withdrawing medically provided hydration or nutrition, providing palliative sedation to the point of unconsciousness, or engaging in organ donation. As a nurse, I have witnessed my clinician colleagues struggle with their consciences when they are asked to participate in providing advanced life support therapies to patients with very poor prognoses. In pediatrics, some clinicians struggle with reconciling their consciences when medically provided hydration or nutrition is discontinued when a child is dying.
- Why is it important for institutions to have formal mechanisms for managing clinician conscientious objections?
As part of creating a culture of ethical practice, institutions and clinicians benefit from having formal mechanisms to follow when conscientious objections are raised. Models, such as the one offered in the ATS recommendations, help to clarify situations where such objections are justified and offer a means for creating a trustworthy, respectful and transparent process that takes seriously the integrity of clinicians and protects patients from abandonment.
- What kinds of clinician conscientious objections should hospitals accommodate? Are there objections that shouldn’t be ?
The ATS recommendations suggest several reasons to accommodate conscientious objection. Primary among them is to protect clinician integrity and to respect clinician autonomy to avoid participating in acts that violate their personal beliefs and values. Conscientious objection may also be justified to improve the quality of medical care, including identifying needed changes in professional norms and practices.
The ATS recommendations also identify reasons why some requests should not be accommodated. These include when such requests undermine core professional commitments, put vulnerable populations at greater risk for unjust treatment, create undue burden on other clinicians, or cause certain classes of people to be discriminated against in a hostile, malicious or harmful.
- You are also a member of the American Nurses Association’s (ANA) Code of Ethics Revision Advisory Panel. How does the ANA’s revised Code of Ethics relate to the American Thoracic Society’s new recommendations?
The ATS recommendations align well with the 5th Provision of the ANA Code of Ethics: “the nurse owes the same duties to self as to others, including the responsibility to…preserve wholeness of character and integrity…” The Code’s Interpretive Statements clarify that conscientious objection may be justified when the circumstances of a situation exceed moral boundaries or professional moral standards. However, such refusals exclude “personal preference, prejudice, bias, convenience, or arbitrariness.” Nurses and other clinicians at some time or another will find themselves facing an ethical dilemma where their consciences may be violated. It is vital that both clinicians and the organizations where they practice collaborate to provide clear guidance and processes to support everyone’s ability to practice with integrity.