Dr. Weber is director, the Ethics Institute, University of Detroit Mercy, Detroit.
The patient had a long history of substance abuse. When the nurse was assigned to him for the fourth time in the past year, she immediately went to her supervisor. "It goes against my moral beliefs to continue to care for this patient," she said. "He is noncompliant and self-destructive. I would like to be reassigned."
In wrestling with the question of how to respond to this request, nursing administrators realized they had no clear policy regarding what should be done when an employee asks to be excused from patient care responsibilities that are in conflict with her or his ethical values or religious or cultural beliefs.
P. H., director of the hospital's human resources department, was asked to draft a policy to address this issue. She has reviewed literature from the Joint Commission on Accreditation of Healthcare Organizations and has contacted several acquaintances who work in human resources at other hospitals. She has located two policies to use as models. P. H. has noted that they have several common features. Both policies:
- Place initial responsibility on the employee's supervisor, director, or department head to determine whether the employee's request should be honored
- Require that the employee making the request continue to provide appropriate patient care unless and until alternative arrangements are made
- Permit the employee to appeal to another person or group if the supervisor, director, or department head denies the request
- Suggest disciplinary measures for an employee who refuses to provide care
Neither policy provides criteria the supervisor can use to determine whether a particular request should be honored, beyond the need to ensure that high-quality patient care is not compromised. P. H. believes that some requests should be granted and that others should not. All members of a particular profession are expected to carry out certain responsibilities, are they not? Yet a perfectly responsible member of a particular profession can be conscientiously opposed to participating in certain practices that are generally accepted in healthcare today.
P. H. has decided she would like to hear further reflection on the issue and asked to bring her questions to the hospital's ethics committee for advice on the proposed policy. P. H. told the chairperson that she is particularly interested in the committee's thinking on which requests to be excused should ordinarily be approved and which should ordinarily not be approved.
I offer the following comments as a contribution to the committee's deliberation.
Conscientious Objection or Inappropriate Care?
When should a supervisor excuse or temporarily reassign an employee who claims that participation in a particular patient care situation is in conflict with her or his deeply held values? I believe P. H. is correct in thinking that some such claims should be honored and accommodated; some should not.
When, because of a conflict in values or beliefs, an employee asks to be excused from certain care responsibilities, that employee is making one of two different claims. She or he may be saying (1) "It is wrong to do this," or (2) "It is wrong for me to do this." If the employee is making the first statement, she or he is claiming that the patient is not being treated according to professional or ethical standards. An employee making the second statement is saying that the patient is being treated in a way that is not in conflict with generally accepted standards, but that the employee's own personal values do not permit participation in such treatment.
A nurse may, for example, ask to be removed from the care of a dying patient because she believes the physician is ordering diagnostic tests that will not have any impact on how the patient will be treated. This nurse wants to be excused because she believes the patient is not being treated right.
On the other hand, a nurse may ask to be excused from the care of a dying patient because he personally is uncomfortable with the amount of morphine the patient is receiving, even though he agrees that what is being done is fully compatible with medical and hospital standards. This nurse wants to be excused because the care being provided is at odds with his own values or beliefs.
A conscientious supervisor will seek to discern which of the two types of claims an employee is making when he or she requests to be excused. If it is the first, the response will probably need to include efforts to address the appropriateness of the patient care being provided. If it is the second, the response will need to focus only on the question of whether this particular employee should be excused or reassigned.
The rest of this discussion focuses on criteria for responding to the second kind of claim.
Conscientious Objections
Respect for individual conscience is at the heart of respect for human dignity; it needs to be high on any list of moral priorities. On the other hand, healthcare employees need to be counted on to provide the type of care normally associated with their professions. Furthermore, it is essential that high-quality care be provided to all persons in need without regard to their race, creed, life-style, or other such considerations.
It is often difficult to reconcile respect for individual employee values with professional responsibility and with the institution's mission. Policy of the sort being considered here will be improved, I think, if a careful effort is made to write guidelines or criteria for the supervisor or department head who must make a decision in response to an employee's request to be excused. The proposed guidelines (see "Proposed Guidelines" at the end of this article), reflecting discussions held by the ethics committee at Mercy Hospital in Grayling, MI, may be helpful.
When a request to be removed from certain patient care responsibilities includes the three dimensions listed in the Box, supervisors should accommodate the request if such action will not compromise patient care. The supervisor should assure the employee that the request is perfectly appropriate and should make every reasonable effort to remove the employee from the situation.
If, on the other hand, the request does not satisfy one or more of the three stated conditions, it should ordinarily be denied.
Type of Treatment Some employees may find it difficult to provide care for a patient who is an alcoholic and returns to the hospital repeatedly, who has had multiple abortions, who has AIDS as a result of high-risk behavior, or who has a record of child abuse. An employee may have strong moral objections to the behavior of these patients; however, if the moral objection is not focused on the type of care they are receiving, the request should ordinarily not be given further consideration. A professional cares for patients in need even if they have abused themselves or others.
Consistently Held Value The second condition is sometimes difficult to assess in a particular case, but it can serve as a reminder that what should be respected is the employee's beliefs and ethical commitments, his or her personal value system, not just his or her assertion that "I can't do this because it goes against my beliefs." If, for example, a nurse were to claim that it is contrary to his beliefs to use physical restraints on a patient, but he has been involved in the use of physical restraints for years without expressing concern, administrators would have reason to wonder whether they should honor this request.
Responsibility Is Not Fundamental The third condition serves as a reminder that some responsibilities are so fundamental or basic to a particular profession that anyone who has a moral or cultural conflict with that task would have a hard time engaging in the professional role at all. Healthcare workers who, for example, object to being involved in the care of any patient with a do-not-resuscitate order (because they believe that life is a good to be extended whenever possible) need to be reminded to respect patients' right to refuse treatment. Their willingness to provide care may be a sincerely held conscientious objection, but it does not appear to be compatible with basic professional responsibility.
Seize the Opportunity
In response to initiatives from the Joint Commission, many healthcare institutions are reviewing or developing policies on employee requests to be excused from certain care responsibilities. This is a good opportunity for the organization, perhaps through the ethics committee, to develop sound ethical guidelines for responding to those requests.
PROPOSED GUIDELINES
Ordinarily, an employee's request to be removed from certain care responsibilities should be honored when all of the following are true:
- The request is based on conscientious objection to participation in a particular type of treatment or procedure, not a refusal to care for a particular (type of) patient.
- The request appears to reflect a consistently held value of the employee.
- The care responsibility that the employee wants to be excused from is not fundamental to the profession.