E&L 30%

CO in Nursing

Relating to

Nursing

Occurs when nurses

(1) refuse to provide legal and professionally accepted goods or services within their scope of professional competence.

and

(2) justify their own refusal to a procedure/patient by citing it as an act of conscience.

Professionalism (For CO)

Singapore Nursing Board (SNB)

Nursing and Midwifery Council (UK)

Better provision of care can be provided for patients

Professionalism

Principle 5: Practice in a responsible & accountable manner

- Nurses need to accept the consequences of omitting action in nursing practice

- Practice is carried out according to ethical principles, institutional policies & requirements

Principle 9: Practice self-regulation

- Uphold personal integrity, to object if something goes against the nurse's beliefs.

(Singapore Nursing Board, 2018).

Principle 1 Section 4: Act in the best interests of people at all times

- Nurses have the responsibility to inform their colleagues, superiors or their patients that they conscientiously object to a procedure that needs to be done .

- The nurse must also arrange for an equally qualified nurse to take over the responsibility to provide care for the patient

(Nursing and Midwifery Council, 2015).

- Patients can be cared for by nurses who do not have CO, and they can provide better emotional and physical care needed.

- For instance, women seeking abortion services may be more sensitive and require very specific emotional support (Ramsayer & Fleming, 2020). Nurses who raise a CO to abortion will be unable to provide the well-rounded care needed for such patients.

- Thus, by engaging nurses who are comfortable with abortion, it will reduce the likelihood of the poor care standards delivered. (Ramsayer & Fleming, 2020).

Law (For CO)

Termination of Pregnancy (TOP) act in Singapore

Australian Nursing and Midwifery Federation (ANMF)

The Constitution of Singapore

Section 6

ANMF Policy on CO

Section 15

Law

Subsection 1

- No healthcare worker will be obliged to take part in any procedure to terminate a pregnancy if he or she conscientiously objects to it (Singapore Statutes Online, n.d.).

- When exercising CO, nurses are required to take proper measures to ensure that the patient's preference, safety, quality of care and medical directives are not disrupted.

- No discrimination or punishment will be allowed for nurses/midwives who raise any valid CO (Australian Nursing and Midwifery Federation, 2017).

Subsection 1

- Everyone is allowed to practice his or her chosen religion and to proclaim religious values.

- As such, if a nurse wants to conscientiously object in doing a procedure on religious grounds, he or she should be given the right to exercise CO (Singapore Statutes Online, n.d.).

Ethics (For CO)

The need to protect the moral integrity

American Nursing Association (ANA) Code of Ethics

Personal autonomy and having the right to conscience

Ethics

Is the treatment really necessary?

- Circumcision of newborn males is a medically sound procedure, but it is not medically necessary. Research has shown that there is only a slight difference in overall health between males with and without a circumcised penis (Morris et al. 2017). However, circumcision can be harmful as it could cause discomfort/pain and increases risk of infection, with cases of unintended complications (Morris et al. 2017).

- Newborn males are unable to provide consent to this procedure, yet they have to live with the consequences for the rest of their lives.

- Nurses and patients alike are human beings and should be entitled to having respect for their personal autonomy (Ramsayer & Fleming, 2020).

- It is wrong to ignore the patient’s right to autonomy and in the same way, it would be unfair to treat nurses with a different standard (Rouse, 2012).

- The freedom of conscience is not only restricted to patients. Nurses should also be able to decide on their actions, with the consideration of their conscience. (Ramsayer & Fleming, 2020).

Provision 5 Section 5.4: Preservation of Integrity

- When nurses are faced with situations that challenge moral ethics, nurses are allowed to raise their CO before a procedure.

- CO can be raised on moral grounds when the treatment in question is morally questionable to the nurse or may be inappropriate for the patient (American Nursing Association, 2015).

- By participating in a procedure that goes against a deeply held moral or religious judgement, it compromises nurses' ethical well-being and moral integrity in their nursing practice (Lamb, 2016).

- An example of CO raised by a nurse was when a US Navy nurse objected to the act of force feeding Guantanamo detainees to torture them (Savulescu & Schuklenk, 2017).

- If nurses act against their conscience, it can also cause them to even lose their personal identity, as their moral integrity would be compromised.

Professionalism (Against CO)

Workplace Inefficiency

The Occurrence of Discrimination

"The Code" for Nurses and Midwives by SNB

Professionalism

- The nurse who raised CO would have to find another willing nurse to take over.

- Once another nurse is found, there would be added burden on that nurse since the person would have to take over all the extra work.

- This might cause workplace tension and potentially cause delayed treatment (Nuttall, 2007).

- Workplace adjustments would be burdensome as the veracity of CO is difficult to determine and is time consuming (Card, 2012).

Principle 1: Respect the people's values, needs & rights

- Especially when planning care and carrying out the care plan for patients.

Principle 8: Promote professionalism & uphold public trust

- Nurses need to be conscious about their behaviour and how it can affect others and the profession.

- Nurses should never misuse professional status to cause disrepute or undermine public trust or confidence (Singapore Nursing Board, 2018).

- CO could be seen as discrimination against patients by refusal of care or refusal of doing "unpleasant work" for patients (Edwards, 2010).

- Discrimination would lead to patients feeling hurt or even become self conscious, which may lead to them harboring bad impressions of the hospital by deeming the nurses there as unprofessional, thereby eroding the foundation of the nursing profession.

* SNB refers to Singapore Nursing Board

** "The Code" refers to professional conduct, ethical values & practice standards that every nurse and midwife in Singapore must follow

Law (Against CO)

Abuse of the Rights to CO

Legal Uncertainty

Law

Emergency Cases

- There are laws in place for exceptional situations, such as in the event of a medical emergency, which trumps the right to object.

- Eg. Termination of Pregnancy (TOP) Act Section 6, subsection 3,

which states that "treatment that is immediately necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman" and this will override one's CO (Singapore Statutes Online, n.d.).

- The largely religious and non-verifiable basis of CO results in the laws and policies (to limit the exercise of CO) that are impossible to enforce. This gives rise to the possibility of people abusing CO.

- In some countries, there is rampant abuse of CO arising from racism, prejudice, sexism, preferences, and power imbalances, which ethically compromises the objection too (Giubilini, 2014).

- There is a lack of clarity on the limits of CO and how it can be rejected.

- Even the word "participation" in the treatment of women undergoing abortions can be ambiguous (Ó Néill, 2015).

- Others that are not in the law in Singapore: euthanasia, physician-assisted suicide, withdrawal of life support measures, palliative sedation.

Ethics (Against CO)

A Shift in Focus

Causing Harm to Patients (Non-maleficence)

Pushing Own Values on to Patients

Ethics

- It is unethical for nurses to impose their personal beliefs on the patient without consideration of patient's own values (Young, 2010).

- Since there are two parties involved, it will be unfair to prioritize the nurses' beliefs over the patients' needs and beliefs.

- Nurses usually exercise their rights to object certain procedures for moral reasons, rather than acting based on their morals while carrying out their duties. However, they should try to show through public reason that the nature of the procedures themselves are immoral instead of raising CO.

- When such procedures gain public recognition to be unethical, then the procedures can be excluded from the scope of medical profession.

- Hence, to remove ethical concerns that arise due to CO, attention should be shifted to determining what treatments should and should not be allowed in the work of nurses. (Giubilini & Savulescu, 2018)

- When a patient is denied treatment due to a nurse's CO, the patient's access to medical care is obstructed, which could result in a worse outcome than what might have occurred had the patient received the care at the time it was needed/requested.

No one's individual morals should take precedence

Evaluation

1. CO is widely contended across healthcare professions, largely due to it being heavily influenced by individual opinion, which is very subjective.

2. We have explored the varying points raised by both sides, and both provide sound arguments. In our opinion, it ultimately boils down to whose morals and beliefs ought to take priority in each scenario. It is unfair for either party to take precedence all the time.

3. While primacy of patient welfare over a medical provider’s self-interests is a foundational principle in all healthcare professions, conscientious objections that

are purely self-motivated stand in contrast to this principle.

There is a place for CO

Our Stand

- CO protects and upholds the moral integrity of nurses as long as the care is not compromised

- Also, nurses' autonomy and freedom of speech should be respected and not be oppressed. By allowing CO in nursing practice, it paves the way for liberty in the profession.

- However, we need to ensure that the ability to CO does not reduce the standard of care given to patients. It is also important that it is not abused and be an excuse to shirk responsibility.

Improving Nurses' Rights to CO

Recommendations

- More specific laws and policies, to govern and protect the rights to CO.

- Check & balances to ensure the freedom of CO is not abused, but at the same time also protected.

- Singapore can also set in place a Standard Operating Procedure (SOP) for nurses to follow when they want to raise a CO. For example, it is mandatory for nurses to find a replacement to take over the duty, before the nurse with the CO can fully opt out of the treatment in question.

- Raise the awareness of CO to the general public, so that a social stigma would not be formed against nurses or any other healthcare staff that want to or has raised a CO previously in their work.