Table 1.

Examples of clinical situations that might result in ethical tension or conscientious refusal

PATIENT, GUARDIAN, OR REGULATORY REQUESTSITUATION OF ETHICAL COLLISION
Parents of a young woman in Quebec request a virginity certificateBased on personal moral beliefs, the clinician refuses to examine the hymen of the young woman, despite explicit consent from the young woman herself
Physician pressured to perform cardiopulmonary resuscitationIn a case consistently deemed medically futile, a conscientious clinician refuses to prolong dying, squander resources, and extend patient suffering by repeatedly commencing cardiopulmonary resuscitation2
Government pressures a physician to perform a punitive amputationOrthopedic surgeon told by Afghani government officials to amputate a healthy man’s leg as punishment for theft3
Parents request female genital mutilation for their child as a required part of their belief systemVolunteer physician working in a village abroad as part of an international medical team is asked to perform female circumcision, a procedure that violates his moral beliefs
Patient in Canada demands respect for autonomy in choice of physicianA pregnant woman refuses emergency obstetric care based on the clinician’s sex and race. She demands referral to a female physician of a different ethnic origin
Physician asked to determine fetal sexRequest that the physician determine fetal sex at 12 weeks’ gestation with the expressed aim of choosing feticide if the fetus is not male.4 Based on moral beliefs denouncing discrimination against women, he refuses
Patient request for assisted suicide in jurisdiction where this has been legalizedA young patient with mental illness adamantly requests that a physician prescribe a lethal dose of sedation. Physician refuses
Administrative pressure to increase hospital efficiency at the expense of patient careA physician is disturbed by his inability to provide optimal care for seniors with dementia owing to explicit institutional economic constraints5
Patient asks family physician to be dishonestAn immigrant woman implores her physician to lie to her husband regarding the nature of a previous surreptitious medical visit. Physician refuses to lie, based on moral beliefs
Patient in emergency demands narcotic analgesiaPhysician is suspicious of narcotic abuse6 and refuses to prescribe it
Parents of child refuse consent for life-saving blood transfusionBased on moral stance to protect life, the physician considers legal measures to save the life of the child through blood replacement7
Patient with personal sexual obsession requests surgery to fulfil ongoing erotic fantasiesSome patients with various morbidities, such as those who are transabled, might request procedures that would inflict self-harm. Physician refuses to knowingly inflict harm8