**National Ethics Teleconference**

***The Conscience Clause***

**June 25, 2002**

**INTRODUCTION**

**Dr. Berkowitz:**

Good day everyone. This is Ken Berkowitz. I am a medical ethicist with
the VHA National Center for Ethics in Health Care and a physician at the
VA New York Harbor Health Care System, and I am pleased to welcome you
all to today\'s Ethics Hotline Call. By sponsoring this series of ethics
hotline calls, the National Center for Ethics in Health Care provides an
opportunity for regular education and open discussion of important VHA
ethics issues. Each call features a presentation on an interesting
ethics topic followed by an open, moderated discussion of that topic.
After the discussion, we reserve the last few minutes of each call for
our 'From the Field' section, and this will be your opportunity to speak
up and let us know what is on your mind regarding ethics related topics
other than the main focus of today\'s call.

Before we get started today, I have several brief, but very important
announcements. There are two announcements about changes in our Center.
First, the National Center for Ethics has changed its name, as some of
you may have picked up in my Introduction, we are now the National
Center for Ethics in Health Care. The new name more accurately reflects
our mission and our work.

The second announcement was supposed to be made by our Director, Dr.
Ellen Fox. However, she is running late in a meeting with the Under
Secretary and called me just prior to the start of the Hotline
expressing regret that she could not deliver this news personally, but
asked me to make the announcement on her behalf. A decision was recently
made to relocate the functions of the White River Junction, Vermont
office of our Center to VA Central Office in Washington, DC. The
resulting consolidation of staff and improved access to VA national
leadership are expected to enhance the Center's effectiveness and bring
new opportunities for the Center to effect positive change in VHA health
care. I am sure you will all be hearing more about these big changes for
our Center in the weeks and months ahead.

Finally, the last announcement. Some of you may have noticed that you
did not receive the follow-up e-mail from last month\'s Ethics Hotline
Call on the Core Competencies for Ethics Consultations. This is because
we had some technical problems with the server in Silver Spring,
Maryland and this has prevented us from posting the detailed summary of
our call on our Web site until just yesterday. Now that the summary is
available, we will release the follow-up e-mail from the May hotline
call. If all goes well in our adventures in cyberspace, you should
receive the follow-up e-mail for today\'s hotline call sometime next
week.

**PRESENTATION**

**Dr. Berkowitz:**

As we proceed with today\'s discussion on matters of conscience as they
apply to health care, I would like to briefly review the overall ground
rules for the Ethics Hotline Calls. We ask that when you talk you begin
by telling us your name, location and title so that we can continue to
get to know each other better. We ask that you minimize background
noise, and if you have one, please do use the mute button on your phone
unless you are going to speak. And please, and I can\'t stress this
enough, do not put the call on hold, as automated recordings are very
disruptive to the call. Due to the interactive nature of the calls and
the fact at times we deal with sensitive issues, we think it is
important to make two final points. First, it is not the specific role
of the National Center for Ethics in Health Care to report policy
violations. However, please remember that there are many participants on
the line, you are speaking in an open forum and ultimately you are
responsible for your own words. Lastly, please remember that these
hotline calls are not an appropriate place to discuss specific cases or
confidential information. If during the discussions we hear people
providing such information, we may interrupt and ask them to make their
comments more general.

Now for today\'s discussion on matters of conscience in health care.
From time to time health care workers cite matters of conscience when
declining to participate in the care of a patient. Today we will try to
consider the ethical questions raised in such circumstances. To start
today's discussion I would like to call on one of the Center\'s summer
interns, Cedric Dark. Cedric is a medical student at the NYU School of
Medicine. We are very pleased to have him here with us for the summer.
Cedric, please start our discussion of the conscience clause as it
applies to health care.

**Cedric Dark, Summer Ethics Intern, NY Office:**

Thank you Dr. Berkowitz for inviting me to speak today, and good
afternoon to all of our listeners. In order for me to talk about matters
of conscience for health care providers, things that most jurisdictions
address through some sort of conscience clause, I think it prudent to
provide a little background. Ethical issues regarding matters of
conscience for health care providers occur can when the rights of the
patients and the provider come into conflict. Also, an ethical issue can
arise when an organization seeks to respect both the rights of the
patient and the rights of its staff. Conscience clauses have existed
within the health care system for some time, typically associated with
reproductive health services such as abortion. Today some sort of
conscience clause exists in 44 of the American states and even in some
foreign countries. These clauses have arisen out of respect for our
diversified health professionals, a group that is comprised of people of
different ethnicity, religion and socioeconomic backgrounds. The
conscience clause is derived from the First Amendment right to the free
practice of religion and also from the moral principle of \'do not
deprive freedom\'. As such, one can understand why many Catholic
physicians would be opposed to performing abortions or why many Jehovah
Witness physicians would be unwilling to participate in blood
transfusions. Since these clauses require that a practitioner claim
exemption from a particular procedure on the basis of their own
conscience, we ought to clarify our understanding of the concept of
conscience.

There are at least three viewpoints on this matter. First, conscience
can be interpreted as an internal moral sense that is used to
distinguish wrong from right. Second, conscience could be the
internalization of societal norms, and as such, this version of
conscience would develop through interactions with parents, family,
teachers, religious leaders and eventually colleagues. A final
conception of conscience exists as the attempt to maintain one\'s sense
of integrity. Utilizing these concepts, many different organizations and
legislatures have developed policies for conscientious objection. Most
permit health care professionals the right to refuse to perform certain
procedures or participate in activities that are contrary to their
religious moral belief and which are in violation of their conscience.
Simultaneously, however, patients remain protected by guarantees of
access to these so-called morally objectionable procedures and through
provisions that provide for the transfer of their care to an alternate
provider.

I would like to briefly mention statements from a few organizations. The
World Health Organization, when writing considerations for formulating
reproductive health laws, states that the right of protected conscience
covers only conscience based on adherence to a religious faith. But some
laws on freedom of political, philosophical and other expression may
accommodate a right of nonparticipation in professional practice to
which individuals object on grounds of more general conscience. The
American Nursing Association's Code of Ethics for Nurses states that
where particular treatment, intervention, activity or practice is
morally objectionable to the nurse, whether intrinsically so or because
it is inappropriate for the specific patient, or where it may jeopardize
both patients and nursing practice, the nurse is justified in refusing
to participate on moral grounds. Another proclamation, from my home
state of Maryland, says that a provider cannot be required to perform,
participate in or refer a patient for an abortion, sterilization, or
artificial insemination. In VA the only national policy regarding
matters of conscience is limited to the section in VHA Handbook 1004.2
Advance Care Planning. That policy contains a section called
"Conscientious Objection" that states "a health care provider may
request to the decline to participate in the withholding and the
withdrawal of life sustaining treatment for reasons of conscience." It
goes on to say "in such cases, responsibility for the patient\'s care
shall be delegated to another health care provider of comparable skill
and competency who is willing to accept it." This clause applies to end
of life issues. And another definition offered by one VA facility in
their local policy is similar to the statement from the ANA. At that
facility a conscientious objection is simply an objection to a specific
intervention or care based upon a health care provider\'s religious
and/or moral views. This refers to all interactions which are both
medically and legally appropriate and to which the patient has given
informed consent. Thus, the refusal of the provider solely based upon
moral or religious views and not due to differences in medical opinion
or legal considerations.

**Dr. William Nelson, National Center for Ethics in Health Care:**

Would you say a little bit more about why it is that having a clear
understanding of the conscience clause is so important within the
hospital context or for people that work in the hospital setting?

**Mr. Dark:**

First and foremost the establishment of a conscience clause is a show of
respect to the people that compose our health care system. And, as I
said before, this consists of people of many different ethnic, cultural
and religious backgrounds. In short, a conscience clause reflects the
ethical principles of freedom and respect to all individuals. And there
are, of course, other reasons why conscience clauses are important to
the ethical practice of medicine. First, these clauses may offer broad
protection to various professionals such as physicians, nurses,
pharmacists, or even students that are involved in patient care.
Secondly, conscience clauses assert that conscience is the right of
individuals. And I mean whenever a legal obligation to perform a service
conflicts with an individual\'s religious convictions, he or she has a
mechanism by which they can responsibly transfer care of the patient to
another provider. The third benefit of having conscience clauses in
effect is that it shelters providers against discrimination or penalties
that they might otherwise face when expressing their religious or moral
beliefs.

**Dr. Berkowitz:**

It seems that the conscience clauses are pretty comprehensive. I guess I
am wondering if there are any limits to conscience clauses?

**Mr. Dark:**

There are certainly limits. And as I tried to convey earlier, some
people are actually upset that certain conscience clauses apply only to
particular providers or a limited number of procedures. And these are
often related to reproductive health or end of life issues. Some people
want conscience clauses to be applicable more broadly. But let me
mention quickly two situations in which conscience clauses do not apply.
The first is in an emergency situation: as all people are entitled to
life saving procedures, a procedure that would save someone\'s life,
although possibly against the moral convictions of a provider, must
necessarily be performed by that provider in an emergency situation.
Secondly, and this is typically incorporated into most conscience
clauses, it is not permissible to conscientiously object when doing so
would disrupt the care of a patient. So if I may bring this back to the
law in Maryland, both hospitals and individual physicians are free from
obligation to perform an abortion, sterilization or artificial
insemination. But if that refusal can reasonably be determined to be the
cause of death or of some serious injury to the patient, then the
provider or hospital might actually be held liable. So although this is
a legal implication, it does merit the ethical argument that while it is
good to respect the wishes of the hospital staff, that cannot come at
the expense of sacrificing the care of the patient or the loss of the
patient\'s autonomy.

**Dr. Nelson:**

It would seem to me that what you are saying is that to prevent
abandonment of a patient by his or her specific providers is a crucial
consideration here. But is there an obligation to the hospital to take
care of that patient in general? For example, do hospitals with
religious affiliations have to provide abortions or other procedures
they might find objectionable?

**Mr. Dark:**

Well, there is one last limit to conscientious objection in regards to
access of legally permissible procedures to patients. And this is
primarily encountered in situations when organizations as a whole, and
typically the ones with religious affiliations, attempt to utilize the
conscience clause. Basically any hospital that is receiving public
funding, for instance, must then provide services to the public, and
therefore cannot be opposed to providing certain procedures such as
abortions. So basically the rights of conscience apply to the
individuals who work at that place, and not the institution itself.

I also want to talk about some instances of which I am aware where
people claim the conscience clause, but it is not actually a valid use.
And this occurred in the 1980\'s when some physicians refused to see
patients who were HIV positive, invoking the conscience clause. However,
the clause provides for moral objections and not for objections based on
self-interest such as reducing risk of infection. And obviously hospital
workers must accept some risk of contracting nosocomial infections at
their work place. So in this case we see morality versus self-interest
and this poses an area where we must scrutinize to determine the
acceptability of claims of conscience. There even have been examples of
self-interest claims based on economic reasons. And, as you can imagine,
without appropriate oversight the conscience clause could eventually be
robbed of its ethical use and become a tool to perpetuate discrimination
based on serology, finances or even race or ethnicity.

**Dr. Nelson:**

In thinking about the conscience clause and the concept, it seems like
there are many practical considerations. For example, I think there
really ought to be open discussions between a clinical supervisor and
his or her staff about the concept and how it is applied within that
institution. Or providers should avoid working in a clinical setting
where they are likely to encounter such value conflicts with patient
care. Or providers may also want to discuss their concerns with the
ethics committee before the conflict actually arises in the care of a
specific patient. But apart from those general, very practical
considerations, it seems that it might be appropriate in applying the
concept within the institutional setting that it would be appropriate
for health care facilities and VHA to develop a specific mechanism or
process to review requests to withdraw from a patient's care because of
matters of conscience. Optimally there should be some consistent process
reviewed with the staff, I was thinking, to make that claim of
conscience clause.

**Dr. Berkowitz:**

Why would such a mechanism need to be in place and why do you think it
is so important?

**Dr. Nelson:**

I can think of a couple of points. First, without a mechanism how would
one consistently distinguish genuine claims of conscientious objection
from claims based on avoidance of work such as just sheer laziness or
fear or distaste of certain procedures or dislike or prejudice towards
certain patients? So it seems like there ought to be some type of way to
review and look at those claims. Understanding the true nature and
justification of the claim allows one to then identify the genuiness of
the claim. When assessing the authenticity of such an appeal, you might
consider such factors as the underlying value and their importance to
the individual's identity and also their consistency over a period of
time.

**Dr. Berkowitz:**

Cedric, are there any final things you would like to tell us about
matters of conscience in health care?

**Mr. Dark:**

I would like to echo what Dr. Nelson just said and stress that a major
difficulty with the conscience clause is actually determining the
genuiness or sincerity of a claim. For instance, at some point in time
it has probably occurred that an exhausted ob-gyn resident who actually
has no moral objection to doing an abortion might claim the conscience
clause just to catch up on sleep, and obviously cases like this must not
be permitted to occur. So yes, we have seen that there are times when
people have attempted to claim a conscience clause, when in fact they
have no moral basis for it. The burden really falls on policy makers to
ensure that claims of conscience are reviewed and found to be genuine
and creditable so that both the providers and patients can achieve their
goals.

**MODERATED DISCUSSION**

**Dr. Berkowitz:**

Thank you very much both Cedric and Bill. That still leaves us about 15
minutes for open discussion of today\'s topic, so feel free to introduce
yourself and let us know what you are thinking and what are your
questions.

**Jack Klugh, Chaplain, Fargo ND:**

Well, I heard your comments on this and this sounds quite similar to the
conscientious objector in the Army that I am familiar with. I think a
process is important because it sounds like the doctor, whoever, I guess
it could be anybody, is going to have to prove the sincerity of what
they are trying to move away from. And that would be the process because
it seems like that is just conflict ridden without a process, wouldn\'t
you agree?

**Dr. Berkowitz**:

Sure, and I think most organizational ethics concerns beg for, a process
that is coherent, consistent and transparent to assure that there is
equity and fairness in the system.

**Jack Klugh:**

I also heard earlier that if a person is going to work for a place or
work for a hospital or clinic that receives federal funding or public
money, that hospital must provide all legal procedures---the hospital
itself cannot invoke the conscience clause. People should know this and
maybe shouldn\'t work there because they might run into this. I\'m not
so sure organizations do a very good job about explaining that on the
front end. So for people who are in the system now, they could I think
theoretically cry foul because they didn't know that.

**Dr. Berkowitz:**

Bill, you were just talking with me before the call about one facility
that includes it in their orientation to new employees. Do you want to
expand upon that?

**Dr. Nelson:**

Right. I think Jack raises a good point and that is how extensively does
the institution inform patients of this attempt to try to balance not
only the rights of patients but also rights of the staff. We at the
Center are aware of a few facilities that have developed mechanisms or
processes and at one of those sites in their policy they stipulate that
HR should discuss this topic during a new employee orientation, that is
the clinically oriented or people that are working in a clinical
environment is what I am trying to say. That should be a part of the
orientation process to them. And also, as I think I noted earlier, that
supervisors should be discussing this issue with people that work on
their staff that are clinical health care providers. So I think that it
is something that we may not be addressing nearly as much as we ought to
and it\'s just one of those other organizational ethics issues that we
need to be thinking about and looking at our mechanism and processes for
addressing it.

**Dr. Berkowitz:**

Are there any callers on the lines from facilities that have policies or
formal mechanisms regarding matters of conscience in health care that
would like to tell us about them?

**Dr. Nelson:**

I think in a way that is a statement about how few facilities really do
have the type of mechanism that we've been alluding to, and we don't
have any model that we are offering to you, but just as Jack reiterated
that same point that it might be very useful.

**Dr. Berkowitz:**

Do any of the callers know of cases or situations where providers have
invoked the conscience clause when deciding not to participate in care?
Has anyone out there run into that situation?

**Dr. Yelamanchili,Danville, IL VA:**

Recently we had a situation where in the course of treating patient the
physician feels that PO food is inappropriate, even though the patient
adamantly requests water and feeding. So the physician raised the
question that he should be relieved of his responsibilities regarding
the patient because he doesn't feel it is morally right or ethically
right to feed the patient knowing that the patient is going to aspirate
and may end up dying.

**Dr. Berkowitz:**

And that was actually a case that we had discussed and it was a very
complicated case but the question was could the provider opt out based
on the \'dangerous\' behavior that the patient was requesting to
continue. How did your facility decide to handle that case, if you can
give it in a general way?

**Dr. Yelamanchili:**

We are still working on it and we appreciate your input into that matter
and we are going to finalize it at the end of this week and send you up
some information.

**Dr. Berkowitz:**

I think it is important to go back and maybe review some of the
materials that Cedric discussed in the discussion to really see if that
was a matter of conscience where the provider was trying to opt out of
the case. Having dealt with that case, do you think you might want to
move towards developing some sort of procedure for future cases in your
institution?

**Dr. Yelamanchili**:

Yes. We sincerely hope so. We think it is going to come up in the
future, so we want to develop some kind of policy regarding this.

**Dr. Ware Kuschner, Palo Alto, CA VA:**

Would it be relevant, I haven\'t dealt with this issue so I am speaking
hypothetically, but would it be relevant to bring up an employee\'s
staff work record in trying to make a judgment about the sincerity of
his or her invoking a conscience clause? In another words, is it
relevant, is it germane whether or not someone perhaps has a stellar
work record or perhaps has a borderline work record in terms of effort
or whatever in determining whether or not someone is sincere when they
invoke the conscience clause in moving away from an expected task?

**Dr. Berkowitz:**

I would assume that it is only relevant as it relates to the specific
question. Certainly you are looking for that sense of genuiness as it
reflects a true sense of the person and their integrity and their values
and their own beliefs. And for that to be true you would look for
consistency in their decisions. I suppose if someone was changing a
pattern and that they could tell you why it was a true change in their
values or what that pattern was based on, that that certainly would be
something that should be considered. Bill, did you have something else?

**Dr. Nelson:**

In preparing for today\'s discussion we did a review of the literature
and I also looked in the Encyclopedia of Bioethics, and let me just read
a couple of sentences from the Encyclopedia of Bioethics where it
suggests that in accepting the authenticity of such appeals, we might
for example inquire and they list three things. One is the underlying
values and the extent to which they constitute a core component of the
individual\'s identity. In other words, what is really the depth of
those values and where do they come from. If a Jehovah Witness physician
is saying they want to not provide care in a certain way, they can
describe the depth of their values and where it is coming from.
Secondly, the depth of the individual's reflective consideration on the
issue. In other words, how much have they really thought about this and
analyzed it. Thirdly, the likelihood that he or she that is invoking the
conscience objection will experience guilt or pain or the loss of
self-respect by performing that act. In other words, they are going to
almost suffer if they do something against their conscience. Those are
some guideline questions that are being asked or that we might want to
consider when we are assessing that authenticity issue.

**Chaplain Klugh**:

What about liability here? I\'m thinking when people make these value
judgements about a clinician\'s values, I mean, in this litigious
society in which we live, talk about that, I mean somebody seems like
they are going to be vulnerable here when this decision comes out.

**Dr. Nelson**:

Do you mean vulnerable if we do not respect that clinician's
conscientious objections or vulnerable if the patient isn't cared for in
the way that is the standard of care?

**Chaplain Klugh:**

I think the hospital is going to ensure that the patient will be cared
for. That would just make good sense in terms of common sense. I'm
thinking of, let's just say a doctor comes in and he responds to these
questions, and then the committee disagrees with him and then he takes
them to court. Has anybody got anything to say about something like
that?

**Dr. Nelson:**

I personally am not aware of any situations such as that. I would think
that the committee has to avoid quick judgmental decisions, if you will,
because let's say the parents of a Jehovah Witness patient are saying
that they don't want the blood to be administered to that child. Now it
may be that we may really disagree with them. We just think those
parents are making a wrong, we might even say dumb, decision. So I think
we have to distinguish between sort of the character of the agent, that
is the decision-maker, from the rightness of their particular act or
decision. So I think we need to in a way in general support that
conscientious objection unless there is clear evidence that it is not
genuine.

**Dr. Berkowitz:**

Are there any people from Regional or General Counsel on the line who
might comment on Chaplain Klugh's legal question?

**Dr. Michael Cantor, National Center for Ethics in Health Care:**

I think the answer is that you can always be sued. No matter what you do
or don\'t do, somebody out there will be ready to find a lawyer to take
you to court. In this case though, I think it is important to remember
what we are talking about is probably a supervisory decision. So even if
the committee says we think it is okay or we don't think it's okay, we
are free to object. It is the supervisor who is going to have to order
the physician or clinician and suggest they need to do this as part of
their responsibilities. If the employee decides not to comply with that
recommendation and disciplinary actions are taken, that is where I think
this will probably be played out. Initially internally within the usual
process, and then potentially in court or through litigation. So I think
it turns into a question of subordination or insubordination and the
usual legal problems that revolve around that. That also has I think in
some ways that may be where Ware Kuschner's point about the work record
of the employee may become relevant. If this is part of a pattern of
behavior that is not really related to conscientious objection, then it
may be a case where the employer refuses to go along, we would have a
harder time defending their decision in letting these processes play
out.

**Dr. Berkowitz:**

Then I assume, Mike, that if an institution did have a clear process in
place that was applied uniformly, that that would probably be in their
favor if things actually did get to a legal proceeding?

**Dr. Cantor**:

Absolutely. Assuming that the substance of the process was good as well
as the process itself.

**Dr. Berkowitz:**

And now that we have said all that Chaplain Klugh, practically speaking,
I am not sure that I can envision that really happening if there were
sensitive supervisors. I mean no one really wants to make people do
things that they don't want to do. And I guess the only reason for doing
that would be if it would cause a detriment to the patient not to do it.
Otherwise I would be surprised if people were forced to do things unless
there was very good reason for it. And that\'s sort of a practical guess
as to what happens usually in the field.

**Chaplain Ted Bleck, Canandaigua, NY VA:**

You had originally asked if there were any facilities that had
incorporated a conscience clause in policy. VISN 2 has one buried in its
advance directive policy and it's fairly limited in terms of application
to advance directive issues and the implementation of objection by
practitioner or provider. But it is an example of what we do up in VISN
2 for all five medical centers. It arose out of western New York and was
considered important enough to include in our VISN policies since we
operate as a health system.

**Dr. Berkowitz:**

Yes, and I actually just read that policy because I was discussing with
Chaplain Evans earlier in the week and last week, and I did read that
paragraph towards the back of that policy, and was happy to actually see
it there.

**Chaplain Bleck:**

And as far as experience goes, at least in Canandaigua, we've not had
any opportunity to implement it or use it. Other sites may want to come
online and talk about their individual experiences if they have had any.
I have not heard any percolate up to me.

**Dr. Nelson:**

Ted, you mention about the VISN 2 statement in the advance care planning
document, but at your facility in Canandaigua you actually have a
specific policy or mechanism to address this issue? You are one of the
few.

**Chaplain Bleck:**

Well, since we've gone to VISN level policies for many of the ethics
issues or advanced directive issues, the Network policy supercedes
local. But what we have incorporated is if there is a dispute, we have a
dispute mediation mechanism that is universal across the Network where
the Chief of Staff or Medical Center Director can convene a dispute
mediation committee or team modeled much after New York state legal
requirements.

**FROM THE FIELD**

**Dr. Berkowitz:**

We probably have about 10 minutes left and since again one of the goals
of the hotline call is to facilitate networking between ethics related
VA staff and to facilitate communication between the field and the
Center, we open up the call on the last portion for our 'From the Field
Section,' and this is your opportunity to speak up and let us know what
is on your mind. You can ask us quick questions, make suggestions, bring
problems to our attention, give us ideas, again, please no specific case
consultations, but now is the time where you can open it up to
discussions wider than the conference calls or continue with our
discussion on matters of conscience.

**Ms. Fran Cerere, Syracuse, NY VAMC:**

Just a little bit longer on the conscientious objection, I would like to
know how it would be handled if a primary care provider, for example,
had a conscientious objection and now had to inform the patient and,
therefore, transfer the care. So he wants to tell the patient. How would
he or she handle that?

**Dr. Berkowitz**:

Well, again I don't think that there is a uniform policy or procedure. I
do think that it would obviously be optimal to be open with the patient
to explain to them why the change is being made and the steps that are
being taken to assure that the patient isn't being abandoned and that
their care and the quality of their care is going to be assured. And
beyond that, I am not sure that there is any specific answer. Does
anyone have any specific mechanism? Ted, is it specified up there in
VISN 2 in what to tell the patient?

**Chaplain Bleck:**

We don't have anything specifically in terms of telling the patient.
What we have is a process once a provider has decided there is a
conscientious objection and there is a dispute between the provider and
the patient. We have a way of negotiating that or resolving that.

**Dr. Berkowitz:**

But again, I think we are looking for true sensitivity both to the
patient and to the staff.

**Dr. Nelson:**

I would think it would be important that when the clinician presenting
the reasoning for their objection and why the patient care is going to
be transferred to someone else, that there will be continuum of care
throughout that transfer process, but it is not articulated to the
patient in a way to undermine the validity of the patient's decision to
have a procedure or treatment that the clinician may disagree with. So I
think it needs to be presented in a way not to undermine the patient\'s
own thinking that they want something.

**Ms. Cerere:**

I guess that was my biggest concern too. For example, just use the blood
transfusion, if I were adamantly against it, I would not want to sway my
patient one way or the other in his decision making. So as I said, it
can be a difficult thing to convey to the patient.

**Dr. Nelson:**

Yes, I think it should be communicated in a sensitive way that respects
the patient's rights to make his or her own decisions which the
physician or the nurse may not agree with, so it's an attempt to balance
both sides of those rights if you will.

**Dr. Berkowitz:**

One other point which I was thinking about in doing the background for
this call, and I think Chaplain Klugh sort of touched on it a little bit
in his very early comments on the call, and that sort of got me
wondering whether an organization or health care system can really act
as a moral agent and claim a conscience or is a conscience something
that is really only applicable to individuals in a health care system?

**Chaplain Klugh:**

Did you come to any conclusions Ken?

**Dr. Berkowitz:**

No, but it honestly made me think a lot of whether or not an
organization can claim a moral stance on a particular concern or issue,
or is that really something that an individual has to claim? I guess in
a broader sense we often talk about organizational issues and values,
and that comes up in the literature on business ethics and
organizational ethics also. What exactly is it that an organization is
saying when an organization claims values or moral standing or
conscience?

**Brian Kelly, Battle Creek VAMC:**

I just forwarded you an e-mail string from the VA Pain Mail Group. Some
of the issues that seem to be surfacing in that are kind of typical
within pain management throughout the country and present us an
interesting opportunity to discuss the ethical impact of some of these
things they are doing like contracts that it is okay for you to violate
this three times and then we will stop your opioids.

**Dr. Cantor:**

I think that the issues of pain management or chronic use of opioids for
pain management present question the values which the VA as an
organization needs to respond to based on values, based on policies,
based on legal requirements. Organizations do actually have sort of
sense of values or culture. In VA we talk about the core values of
trust, respect, excellence, commitment and compassion. What those things
mean are not always obvious or clear and people can disagree but
truthfulness, integrity, being honest, being open, making decisions in a
way that is fair both in terms of the process and the substance in the
decision making, those are the sorts of organizational values which have
a big impact on the way that clinical care is delivered. If you look,
for example, at physician assisted suicide, in Oregon it is legal. In
the state of Oregon it is legal for patients under certain circumstances
to request and to receive assistance from physicians to commit suicide.
The VA policy is clearly opposed to that, and even though we have VA
facilities located in the state of Oregon, it is clearly against our
policies to permit those facilities to participate in physician assisted
suicide. Similarly, in the issues related to pain management on a
chronic basis, questions of truthfulness, questions of integrity and the
challenge of balancing the need to provide good care to patients who may
be difficult to manage versus the need to sort of have some core values
such as beyond just respect for patient but also in terms of integrity
and truthfulness, those are the difficult decisions where without having
some core values, organizations lose their way and they fail to provide
guidance to their employees. And I don't just mean policies, but in
terms of whether or not those policies are interpreted and enforced
consistently and without values I think organizations potentially could
dangerously subvert or even twist the goals of medicine.

**Dr. Berkowitz:**

I agree Mike. And again, what we are really looking for is openness and
consistency and how they express those values and how they play them
out.

**Dr. Cantor:**

Exactly. And the articulation of values in itself, I think, is an
important, and difficult at times, process but without doing that you
won't be able to justify, understand, and therefore implement the
policies in a way which makes good sense both for our staff but most
importantly for the veterans we take of.

**Chaplain Klugh:**

I guess the part that hangs me up with this. First of all I need to do
some reading about it, which will be good. When we talk about money,
basically if you are going to work here, you receive federal funding.
It's incumbent that you adopt the values of the organization, and that
is, I guess, I'm thinking like if you don't adopt these values, you need
not work here. And that is kind of in some way is saying we only want a
certain type of person that has these values. Now I think in terms of
what you are describing here in very generic and general terms, honesty
and things like that, that's broad enough where that is good. But I
think down on the street where you talk about some very complicated
things here, is it in one way saying that hospitals that receive federal
funding only want a certain type of physician that has a certain type of
values because this is the kind of work we do. Am I making any sense?

**Dr. Berkowitz:**

Well, I think what you are trying to examine is complicated. Obviously
you shouldn't work in a place if you don't generally agree with the
values and the mission of the organization. But then when it gets down
to more of a microlevel, there are still certain things that might
happen that you are opposed to or that you won't participate in. I think
that part of what you are asking is a legal answer that I am not
prepared to, shouldn't and won't give, but there are many things that
are tied to conditions of funding, and I guess the right to access a
full spectrum of care in certain systems seems to be one of them. I
guess then it is up to the institution to decide whether or not to
accept that funding if it is going to change the conditions of health
care in a way that they are not willing to provide it. So I do think it
is a complicated question. Unfortunately, I do think we are out of time,
and I would like to end the call. I need to thank everyone who worked
hard on preparing the call, on conceiving it and planning it, especially
Bill and Cedric. It's really not a trivial task, and I appreciate their
efforts. The next call is Wednesday, July 24, from 1:00 to 1:50 Eastern
Time. Look to our Web site and to your Outlook e-mail for details and
announcements in mid-July. Again, if cyberspace cooperates, you will be
getting the follow-up e-mail for this call hopefully next week. And
again, you will get the follow-up e-mail from last call by the end of
this week. And those e-mails do contain the summary of the call, the
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and didn't, and also please let us know if you have suggestions for
topics for future calls. Again, our e-mail address is
vhaethics@med.va.gov or vhaethics on the Outlook system. So thank you
all and have a great day.