Table 7 Overview of broad reasons used to argue for or against CO

++: Broad reason containing only narrow reasons arguing for CO

CO protects HCP (+ 5/− 0; rm.:9)[MR]

“We live in a society that has become increasingly individual over time, with citizens encouraged to seek what is best for themselves. In one sense, a right of conscience is a counter, focusing as it does on perceived obligation, not self-satisfaction. But the right is strongly individualistic, crediting the individual’s conviction against the general perception of what is socially desirable. One might think that creating a legal right, especially a broad one not limited to religious conviction, will contribute to an unhealthy sense that each individual judges for herself, giving little or no weight to a sense of community and to prevailing opinions within the society about what is needed.”[15]

Ignoring conscience of HCP is a form of discrimination (+ 3/− 0; rm.:3) [MR]

“Their feeling that they have yielded to compulsion and violated their most deeply held beliefs and principles may involve profound resentment and loss of self-respect.” [18]

Freedom of conscience (+ 2/− 0; rm.:7) [MR]

“They assert that, because provision of care can be conscience based, full respect for conscience requires accommodation of both objection to participation and commitment to performance of services such that the latter group of providers also have the right to not suffer discrimination on thebasis of their convictions.” [19]

Practice of disclosure creates risk for the HCP (+ 5/− 0; rm.:13) [PR]

“Ironically, in most jurisdictions, the same facility-religious or not-may alternate between refusing and willing. For example, a clinic that only refuses to provide nontherapeutic abortions typically will have to accommodate a doctor who will not participate in therapeutic abortions, sterilizations, or contraceptive care.” [21]

Religious convictions form conscience (+ 3/− 0; rm.:7) [RR]

“Religious beliefs, which statutes and philosophical traditions recognize as a basis for acts of conscience, may be of as fundamental significance to a willing provider as they are to a refuser.” [21]

Controversies in religion-based argumentation (+ 2/− 0; rm.:2) [RR]

“To highlight exclusively religiously based conscientious objection to the neglect of professional conscientious objection renders conscientious objection a strange and alien phenomenon to the nonreligious. More importantly, to do so erroneously suggests that the professional has no positions concerning the ethics of her own practice.” [20]

+: Broad reason containing predominantly narrow reasons for CO

Respecting importance of conscience or CO (+ 11/− 1; rm.:24) [MR]

“When we describe a person as having acted on the grounds of conscience, we typically mean that she “acted on the basis of a sincere conviction about what is morally required or forbidden.”15 Thus, claims of conscience can be understood as a subset of moral claims generally one that connotes a strong link with individual identity and a preference for suffering significant burdens rather than acting against conscientious belief.” [18]

Criteria for CO (+ 9/− 2; rm.:36) [MR]

“It must be consistent with the HCP’s other beliefs and actions, particularly those in proximate areas of concern.” [24]

Moral integrity needs to be respected (+ 5/− 1; rm.:22) [MR]

“A moral system that tolerated intolerance would seem internally inconsistent’.” [24]

Normative value of CO (+ 4/− 1; rm.:13) [MR]

“Conscience, however, is not so one-sided. Nor is medical decision-making so straightforward. First, medical decisions -especially those involving questions of life and death - inspire divergent moral convictions. Second, as I will explain, medical decisions do not simply implicate conscience for the provider. They should be thought of instead as involving, at minimum, three parties: patients, providers, and institutions. This three-sided relationship complicates moral decision-making, with each party asserting potentially conflicting claims.” [22]

Conscience is closely related to identity and sense of self (+ 4/− 1; rm.:8) [MR]

“Acting according to conscience has real importance less because it is about being (morally or politically) right than because it is central to being a whole person. Both theory and experience indicate that conscience is closely related to one’s moral integrity or sense of self.” [21]

Respect for autonomy (+ 3/− 1; rm.:10) [MR]

“Professional conscientious objection in medicine is an instance of the autonomy of the professions from what is simply legal.’ Professional conscientious objection differs from religiously grounded objection by being reason-based.” [20]

Religion does not permit involvement (+ 6/− 1; rm.:16) [RR]

“A different basis for possible differentiation concerns what is at stake. Perhaps religious objectors usually perceive that more is at stake, including their eternal welfare. This sense of magnitude of impairment might be related to what a claimant would be willing to sacrifice to avoid doing a wrongful act.” [15]

Safeguarding conscience (+ 6/− 1; rm.:23) [LR]

“As a two-way street, the conscience clause acknowledges the legitimacy of conscience at the level of institutions, while preventing institutions and individuals from discriminating against those whose consciences differ.” [20]

+−: Broad reason with equal amount of narrow reasons for and against CO

Justifying professional CO (+ 3/− 3; rm.:9) [PR]

“A final variation concerns public attitudes. If the community is deeply divided over whether a form of health care involves a serious wrong, there is a powerful argument that no individual or institution should be required to provide it.” [15]

Organisational ethics require consideration (+ 1/− 1; rm.:2) [PR]

“Organizational ethics is a systematic examination of the morality of collective actions in human institutions dedicated to some specific purposes in society. The ethical “code” or commitment of a specific institution is now customarily expressed in its mission statement. This is in a way the “conscience” of the institution.” [17]

Legality argument (+ 2/− 2; rm.:14) [LR]

“Ultimately, there is no real possibility of engaging in the conscience rights discussion with total deference to the law because the discussion is precisely about what the law should be. In the end, the legality argument is tautological and fails to advance the claims made by forced-access advocates.”[23]

-: Broad reason containing predominantly narrow reasons against CO

Requirement to offer a service (+ 1/− 2; rm.:11) [MR]

Already we hear ethicists suggesting that physicians must separate their personal moral beliefs from their professional lives if they wish to practice in a secular society and remain licensed as fully functioning physicians. [17]

Institutional refusal (+ 4/− 10; rm.:23) [PR]

“When an entire institution refuses to deliver common medical procedures, like contraception and abortion, the risk to patients is further magnified. First of all, access becomes a more significant issue. Patients’ choice of a healthcare facility is more limited than their choice of an individual doctor.” [22]

Degree of involvement among HCP is different (+ 1/− 2; rm.:5)[PR]

“The intrinsic relevance of degree of involvement is more debatable. According to most people’s ordinary sense, if a person’s job calls upon her to receive answers from questionnaires that admitted patients have answered and to exchange a few words with those patients, an objection to such contact with the patients who happen to be entering to receive abortions would be unreasonable.” [15]

Religious toleration has multiple dimensions (+ 1/− 2; rm.:3) [RR]

“Moreover, secular religiousity, which supposedly tolerates differences, does so only within a narrow range of so-called “values” that are supposedly “free” of religious or religious taint. But secular religiousity is itself an orthodoxy. Its “values” are based in democratic procedures, personal preference as the basis for religious choice, commitment to a free market economy, the commodification of health care, and an eschewal of religious belief. To deviate from this notion of religious “neutrality” in public policy is to be “undemocratic,” prejudiced, and intolerably sectarian.” [17]

- -: Broad reason containing only narrow reasons against CO

Imposing own beliefs (+ 0/− 2; rm.:7) [MR]

“The “Imposing Your Beliefs” Argument Imposes a Rejection of Hippocratic Principles.” [23]

Critique of the conscience clause (+ 0/− 2; rm.:2) [LR]

“Immunity goes far beyond what is necessary to protect the moral integrity of medical providers. It destabilizes the medical profession’s duties to do no harm and respect patient autonomy. It endangers the very trust upon which the profession relies.” [22]