Nurses' attitudes toward,perceptions of,and experiences with conscientious objection

Background

As a moral value in nursing practice, conscience takes care of ethics a step forward. Nurses are morally responsible for their patients, their institutions, and, most importantly, themselves. Therefore, they feel conscientiously challenged by situations that conflict with their values and moral beliefs, resulting in moral distress. Conscientious conflict following conscientious distress results in conscientious objection (CO) in certain situations.^1,2

CO is a person’s refusal to fulfill a legal obligation or duty due to their ethical values, religious beliefs, and ideological affiliations. ³ In nursing, it refers to a nurse’s refusal to perform an action or participate in a certain situation based on their conscience. ⁴ The Canadian Nurses Association ⁵ defines CO as a situation in which a nurse informs their employer of a conflict of conscience and the need to refrain from providing care because a practice or procedure conflicts with their moral beliefs.

According to the nursing law of 1954 in our country, nursing is defined as follows: the title of nurse is given to those who graduate from faculties and college providing undergraduate education in nursing in Turkey and whose diplomas are registered by the Ministry of Health, and those whose equivalence is approved by completing their education abroad in a nursing school recognized by the state and whose diplomas are registered by the Ministry of Health. ⁶ In addition, according to the Nursing Regulation dated 2010, the nurse using knowledge, skills, and decision-making abilities gained through vocational training, nursing care should be provided to people in all stages of life, starting from perinatal period, within the framework of professional standards and ethical principles, in every environment where they live and work. ⁷ Based on this, the text “Ethical Principles and Responsibilities for Nurses” was published by the Turkish nurses Association in 2009. In this document, it is mentioned to give fair care without any discrimination of race, religion, and political opinion. However, there is no expression regarding the concept of conscientious objection in the document. ⁸

Turkish law recognizes physicians’ right to CO, but the scope has not been clearly defined. The relevant articles stipulate that physician have the right to deny care to patients for professional and personal reasons. However, they also stress that a physician’s refusal to treat a patient is unacceptable because it denies the patient their right to healthcare (Articles 18–19). ⁹ No Turkish law addresses nurses’ right to CO. There is no research on nurses’ perceptions of and experiences with CO. There is only a small body of research on the effects of conscience on nursing interventions.^10,11

CO in healthcare services has been a hot topic of discussion. Some people are for CO, while others are against it. Those who advocate CO argue that it is a fundamental human right. Article 9 of the European Convention on Human Rights stipulates that “[e]veryone has the right to freedom of thought, conscience and religion.” From this perspective, forcing a person to act against their religious and moral beliefs is a form of discrimination and a violation of human rights and ethical values. Supporters of CO also maintain that freedom is a fundamental prerequisite for providing good healthcare provided that CO is limited.^12,13 Opponents assert that healthcare professionals are supposed to use their knowledge and skills to treat and care for their patients and should never prioritize their values and beliefs over those of their patients. ¹³ They have also raised concerns that CO may place a burden on patients and other colleagues, reduce the quality of health services and care, disproportionately affect those living in rural areas, and result in discrimination and abuse.^12–14

Research shows that nurses would like to exercise their right to CO in different situations, such as administering a futile treatment that causes nothing but suffering, providing technologically assisted treatment for brain-dead patients, managing a neonate’s pain during medical procedures, and taking part in procedures like abortion, sterilization, assisted reproduction, family planning, euthanasia, and organ harvesting.^13,15–17 Yalım ³ and Keleş et al. ¹⁸ argue that more and more Turkish healthcare professionals are refusing to care for certain patients due to their biological sex and taking refuge in the concept of CO to justify their decision. The researchers attribute this trend to the dominance of Islamic values in political and public discourse in recent years in Turkey. However, this situation is incompatible with nursing professional, which should not discrimination while caring to patients.

The American Nurses Association, the Australian Nursing and Midwifery Federation (ANMF), and the Canadian Nurses Association have laid out ethical codes addressing CO. ¹² The concept of conscientious objection is included in the revised 2021 ethical codes of the International Council of nurses (ICN). In cases where a particular procedure or research study conflict with nurses’ moral beliefs, conscientious objection can be applied without violating peoples’ rights to receive healthcare. ¹⁹ Although the Turkish Nurses Association uses the ICN Ethical Codes as a guiding document Turkey has a huge gap in legislation regarding CO. Therefore, this study had four objectives: (1) eliciting information on how Turkish nurses perceive CO, (2) revealing whether their moral beliefs affect the care they provide, (3) determining their experiences with CO, and (4) identifying existing or potential issues of CO. We believe that our results will help us develop an ethical perspective that strikes a balance between nurses’ right to CO and patients’ right to healthcare.

Design

This study adopted a qualitative approach to determine nurses’ attitudes toward, perceptions of, and experiences with CO. Data were collected through semi-structured interviews.

Setting and participants

The study was conducted between October and November 2020, and 21 nurses were recruited using snowball sampling, a non-probabilistic sampling method. After snowball sampling, a population pool of potential participants was created. However, purposive sampling method was used to ensure diversity among inclusion criteria and those who agreed to participate in the study. I was preferred that the participants included in the sample were from different clinical and different cities. The inclusion criteria were (1) working as a nurse, (2) agreeing to participate, and (3) being 18–65 years of age. Participants had a mean age of 35.1 (min: 23; max: 56) and a mean work experience of 12.8 years Table 1 shows the participants’ demographic characteristics.

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Table 1.

Demographic characteristics.

Demographic characteristic		N
Gender	Woman	19
	Man	2
Age (years)	20–29	8
	30–39	7
	40–49	5
	50–59	1
Education (degree)	High school	1
	Bachelor’s	17
	Master’s	3
Place of work	Public hospital	11
	University hospital	10
Department of duty	Intensive care	5
	Emergency	4
	Obstetrics	3
	Palliative care	2
	Psychiatry	2
	Infection	2
	Pediatric intensive care	1
	Operating room	1
	Oncology	1
Work experience (years)	<5	6
	5–9	4
	10–19	5
	≥20	6

Data collection

Data were collected using a semi-structured questionnaire eliciting information on (1) demographic characteristics and (2) participants’ views of the universal values of the nursing profession.

Before starting interview questions, the participants were asked whether they knew about the concept of conscientious objection. The concept of conscientious objection was defined for all nurses with or without knowledge to create a clear concept and common language. With the examples given by the participants, it was verified whether they understood the concept or not. The interview questions were as follows:

i. Have you ever refused to implement a nursing intervention because it felt morally wrong to you? If so, why?

Data were collected online (Zoom) due to the COVID-19 pandemic. All interviews were audio-recorded with the participants’ permission. A separate link and password was created for each interview for security reasons. The researchers emailed the link and password to each participant. ²⁰

Each interview took 35–60 min. New participants were recruited until data saturation was reached. In other words, data collection was terminated when additional data did not contribute to further information or insight.

Data analysis

The data were analyzed using thematic analysis in six steps ²¹ : (1) becoming familiar with the material by reading it openly, (2) generating tentative codes, (3) searching for themes, (4) evaluating themes, (5) defining and naming themes, and 6) writing them down. The researchers transcribed the interviews and assigned protocol numbers (N1, N2, N3, etc.) to them. They used those numbers during archiving, analysis, and reporting. They read all the interviews to get an idea about the whole text and understand the data. Two independent researchers analyzed the data simultaneously to ensure reliability. They developed themes and sub-themes. They consulted a third researcher about the themes they were not sure about. During thematic analysis, they brought together recurrent and original statements. They used the direct quotations that best described the themes and sub-themes.

Ethical considerations

This study was approved by the Assessment and Evaluation Ethics Subcommittee of Gazi University (Project No: 2020–499; Date: 09.24.2020).

Prior to data collection, the researchers informed all nurses about the research purpose and procedure and emailed them the informed voluntary consent form. Each participant signed the form before the interview. The researchers also obtained verbal consent from the participants before the interviews. They transcribed each interview on the same day and deleted the audio record from the online platform for privacy reasons.

Professional values

Participants referred to “ethical values” when they addressed the universal values of the nursing profession. They also described social and personal values under the theme of “moral values.” Care, holistic approach, and solidarity were the fundamental values they focused on during nursing interventions.

Regarding ethical and moral values, one participant said the following:

Our ethical values, such as beneficence, non-maleficence, justice, protection of patient privacy, and patient autonomy, are specified in professional codes. We should also take into consideration our moral values such as being tolerant, patient, conscientious, and compassionate based on love and respect. Conscientiousness and compassion are particularly important. We should approach our patients with our hearts. Knowing stuff and putting skills into practice does not cut it; we should adopt a holistic approach when dealing with patients. (N8)

Some participants considered “not discriminating between patients” as a fundamental value of the nursing profession within the scope of the principle of justice.

I’m saying this as a Muslim. We’re responsible for one another; that’s God’s will. No matter what they believe in, no matter what race they are.…to me, people are people; it could be a peasant, a VIP, a shepherd, or an engineer; it could be someone who worships idols or cows; I don’t care. (N7)

All participants regarded care as an important professional value.

Care, always, all the time, no matter what the circumstances are, whatever the patient needs…water, food, whatever they need…Care has always been a priority to me. (N19)

Some participants stated that adopting a holistic approach is a fundamental value of their profession.

I think a holistic approach is critical. It’s one of the essentials of the nursing profession…We cannot just treat the patient and leave it at that; we should approach them from a holistic perspective. (N3)

Most participants opined that solidarity is another fundamental value of nursing.

Some colleagues end up doing shifts of eight, ten, and even 24 h under stress. So, should we share patients? Yes, we should. We can do it without going off the rails and without compromising our moral and ethical values. (N7)

Table 3 shows the themes and sub-themes under “experiences with CO.”

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Table 3.

Context of experiences with conscientious objection and relevant themes.

Context	Theme			Statement
	Main theme	Theme	Sub-theme
Experiences with conscientious objection	Not providing/not wanting to provide healthcare	Patient characteristics	Patient being prejudiced against the nurse	Being the subject of a reaction
			Hostile patient	Thinking that the patient is not worth it
			Terrorist patient
			Patient convicted of rape
			Patient who killed a woman
			Violent or abusive patient
			Patient who attempted suicide	Inability to make sense of the patient’s behavior
			Patient with AIDS	Having a fear of infection
			Patient with alcohol and substance use disorder	Thinking that the patient cannot deal with it
			Bedridden patient	Thinking that quality healthcare cannot be provided
		Religious beliefs	Considering the patient’s lifestyle	Not providing healthcare services to sex workers or those who attempted suicide
			Abortion	Thinking that it is a sin to kill a living thing
			Unwillingness to provide healthcare to the opposite sex	Providing healthcare according to religious rules
		Cultural attitudes	Discriminating between patients based on their sex	Considering the patient’s privacy

Not providing/not wanting to provide healthcare

Participants stated that they did not want to care for violent patients, those with AIDS or substance disorders, and those who were prejudiced against nurses. The following are some of their remarks:

We had a patient who spat her food on the face of a nurse who was wearing a turban. She [the patient] was extremely grumpy. So, that colleague and others who were wearing headscarves did not want to care for her. (N8)

Participants did not want to care for bedridden patients because they described them as “difficult patients.”

The newbies [young nurses] didn’t want to care for a patient with Crimean–Congo hemorrhagic fever because they didn’t know how to treat him and how to protect themselves. We were like that too. One of them said, “I don’t want to care for that patient. Give me three patients if that’s what it takes, but I just don’t want to go near that patient.” So, a more experienced nurse handled the case instead. We were okay with it because we thought it was the best for her and for us. (N5)

Participants stated that they had some colleagues who exercised their right to CO in some cases due to their personal or their patients’ religious beliefs.

There was a sex worker in our ward. A colleague of mine didn’t want to care for her. Another colleague of mine didn’t want to care for a patient because of the patient’s religious beliefs.…Some colleagues do not want to care for suicide cases. I’ve had some colleagues who are like, “The patient already wanted to die anyway. Besides, God is the giver and taker of life.” So, because of their religious beliefs, they didn’t want to care for suicide cases. (N8)

One participant stated that some nurses did not care for the opposite sex on account of their religious beliefs.

A male nurse in the clinic didn’t want to administer an injection to a female patient. He said that he didn’t want to do it, and actually, he didn’t do it because of his religious beliefs. (N12)

Some participants noted that they sometimes preferred not to care for the opposite sex because of not only religious beliefs but also social norms and patients’ cultural backgrounds. In other words, some nurses did not want to care for some patients because of privacy concerns. Here are some of their comments:

We try to protect the patient’s privacy when we catheterize him or when we give him perineal care…We sometimes have to leave the genitals open in some interventions. In those cases, male nurses care for male patients, and female nurses care for female patients. (N16)

Table 4 shows the themes and sub-themes under “possible effects of CO.”

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Table 4.

Context of possible effects of conscientious objection and relevant themes.

Context	Theme
	Main theme	Theme	Sub-theme	Statement
Possible effects of conscientious objection	Positive effects	Helping update professional norms	Social norms changing over time	Contributing to the development of the profession
		Easing the conscientious burden of nurses	Not participating in CPR in elderly patients	Protecting nurses from the burden of conscience
			Care of end-stage cancer patients
			Caring for newborns with anomalies
		Maintaining the team dynamics	Serving in a working environment where moral values are observed	Preventing burnout from spreading to other nurses
		Respect for patients' personal beliefs	Respect for patients' religious beliefs	Respecting the patient’s lifestyle
	Negative effects	Abuse	Leading to arbitrary practices	Setting the framework
		Patients being denied healthcare	Risk of harming patient rights	Violating the patient’s right to health
		Damage to professional ethics	Turning it into a habit	Engaging in inappropriate attitudes and behaviors under the pretext of CO
		Increased workload for nurses who do not exercise their right to CO	Nurses avoiding difficult interventions	Causing disruption to medical practices
		Negative perception of nurses who exercise CO	Negative reactions from colleagues	Exclusion

Positive effects

Some participants believed that CO could help update professional norms.

Social and personal values change over time. What mattered to us 10 years ago means nothing now. This is particularly important in psychiatry, but it also applies to intensive care. They [professional norms] should be revised constantly. There may be some issues that are in conflict with social values.…We cannot think of professional values without considering social values. (N10)

Most participants noted that CO could set nurses free from the burden of conscience.

I find it wrong to break the ribs of a 90-year-old patient to give him CPR, but I’d participate in it.…I’ve always thought that there’s something wrong with breaking the ribs during CPR until blood comes out of the patient’s mouth just for the sake of doing it. However, would I be a part of it? Yes, I would. (N7)

Some participants thought that CO could help healthcare professionals maintain the team dynamics.

Healthcare professionals don’t want to work in clinical environments that are in conflict with moral values because working in such environments leads to burnout. Let’s say a member of the healthcare team experiences burnout, which spreads to other members. So, they make a decision that might set his mind at rest. This is about the team dynamics. (N10)

Some participants pointed out that CO could encourage healthcare professionals to respect patients’ personal beliefs during medical interventions.

Some patients don’t want to undergo some care practices because of their religious beliefs, like not shaving the beard or not touching another person’s skin…It’s especially the elderly who come up with such requests. But things change in the ICU…I mean, I don’t know whether I should give the patient proper care or not. (N13)

Negative effects

Most participants were concerned that CO paves the way for abuse.

People should not abuse it [conscientious objection]. I mean, what if a nurse says, “I don’t want to give an enema because it is my conscientious objection,” or what if she says, “I don’t want to catheterize the patient because it’s against my religious beliefs.” Who is going to do all those things then? I always think that…what you believe in is your business, not mine. (N17)

Some participants focused on the possibility that CO might deprive patients of their right to healthcare.

Those patients are denied their right to healthcare, or may receive inadequate care. After all, it [right to health] is a fundamental right. So, conscientious objection may cause some problems for patients. (N19)

One participant claimed that CO might jeopardize professional ethics.

Professional ethics comes into the picture here. A nurse has the right to refuse to care for a patient. But why would she use that right? She might think that she might do something wrong and harm the patient. So, she has the right to say, “I’m out, I can’t do this” or “I don’t feel comfortable doing this,” and might want to use her right to conscientious objection. But she should have moral values. She should not turn it into a habit. (N7)

Most participants stated that nurses who were against CO might end up working harder than they should because of their colleagues who enjoyed their right to CO.

What if all healthcare professionals exercise conscientious objection because of their beliefs? Who is going to care for patients?…Then, we would have to do all the work, while others just step aside. Conscientious objection might end up being a way for nurses to cut corners. (N9)

Some participants argued that nurses who exercised CO might be subjected to negative stereotypes, prejudice, and scapegoating.

Let’s say euthanasia is legal, and you participate in it. Can you imagine how it looks from the outside? I mean, because of our religious beliefs and our pedigree…People would be like, “How can you do such a thing? Don’t you have any conscience?” Life would be tough for those who participate in it…they might be ostracized, or others might turn against them. (N5)

Participants commented on the grounded and groundless scopes of CO. Table 5 shows the themes and sub-themes under the context of “scope of CO.”

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Table 5.

Context of scope of conscientious objection and relevant themes.

Context	Theme			Statement
	Main theme	Theme	Sub-theme
Scope of conscientious objection	Grounded scope	Provided that consensus is reached by the healthcare team	Referring the patient to a colleague	Taking into account the working conditions of the healthcare team
		Provided that it is limited	Pregnant nurses not providing care for patients with infectious diseases	Protecting the health of the nurse
			In interventions other than acute cases	Paying attention to the patient’s vital conditions
		In end-of-life medical decisions	Terminal patient care	Engaging in serious questioning of conscience
			Futile treatment
			Euthanasia
		In situations that cause moral distress	Providing healthcare to a terrorist	Protecting the moral values of the nurse
			Providing healthcare to a rapist
			Providing healthcare to a patient who has killed a woman
			Providing healthcare to a patient who has committed violence against someone
		If it conflicts with the nurse’s personal values	Stem cell transplant	Conflict between medical practices and the nurse’s personal values
			Abortion
			Genetic research
			Surrogacy
	Groundless scope	Considering the patient’s biological sex	Refusal to provide healthcare to patients of the opposite sex	Accepting gender-based CO
		Ignoring the dynamics of the hospital environment	Considering ideological and religious beliefs	Not disrupting healthcare service
		Ignoring the core values of the profession	Discriminating against patients	Providing healthcare to everyone who needs it
		Disrespecting the patient’s medical decisions	Judging the patient’s medical decisions	Reacting to the patient’s autonomous decision

Grounded scope

Most participants stated that they could agree with CO as long as the healthcare team reached a consensus on it.

You can’t make a decision about conscientious objection on your own. Conscientious objection is something you decide together with the patient or the healthcare team. I don’t accept conscientious objection if one person says, “I don’t want to do this and that.” (N9)

Some participants noted that they would accept CO as long as it was limited.

The whole healthcare team can think about it and accept a member’s conscientious objection decision if the situation doesn’t jeopardize the integrity of the patient and if the patient doesn’t need acute care. However, at that point, personal interests cannot be an excuse for conscientious objection. (N10)

Most participants pointed out that healthcare professionals could exercise CO regarding end-of-life medical decisions.

It’s a discomforting feeling. I mean, from a religious perspective, God is the giver and taker of life. We have found and still find ourselves in a moral dilemma…we ask ourselves, “Are we stopping the patient’s clock now?” I’ve been there a couple of times. Especially when the doctor says, “pull the plug.” I’ve shut down the devices a couple of times, and I just couldn’t get over it for a couple of days. We did it for the sake of the patient. (N8)

Most participants emphasized that nurses had the right to CO in situations that caused moral distress. Here are some of their comments:

Suppose a healthcare professional thinks differently from others when it comes to abortion. In that case, she should have the right to conscientious objection. She should have the right to say, “This is what I think about it, and so I’m not going to be a part of this team.“…Thus, if she finds herself in a situation that contradicts her moral values, she should have the right to conscientious objection. (N10)

Rapists, child molesters, terrorists, those who kill women and children, and those who inflict violence on healthcare professionals, like those who stab, attack, and kill them…I would like to use my right to conscientious objection to not provide healthcare to such people. (N1)

Some participants were of the opinion that nurses had the right to CO when it came to interventions that were in conflict with their personal values.

If it’s about the personal values of the healthcare professional regarding issues like euthanasia, stem cell transplant, genetic research, abortion, and surrogacy… conscientious objection comes into the picture all over the world. It’s probably the same in Turkey, with the changes in social dynamics and what not.…I think nurses should have the right to conscientious objection in situations that conflict with their values. (N10)

Groundless scope

Most participants regarded CO as groundless when it came to refusing to care for patients of the opposite sex.

Conscientious objection is out of the question when it comes to caring for patients of the opposite sex…You should not choose this profession if you think it’s against your religious beliefs; because you deal with people, whether it’s a man or a woman. (N8)

Most participants noted that healthcare professionals should consider the dynamics of the hospital environment and not provide healthcare based on personal beliefs.

How can a nurse refuse to perform or participate in a legal abortion procedure? If it’s her ideology, the hospital is not a place for ideologies; if it’s her religious beliefs, the hospital is not a place for religious beliefs. (N7)

Some participants found CO unacceptable because they believed that it defied the core values of the profession.

Let’s say the patient is a terrorist, a murderer, or an alcoholic…There’s no way you can exercise conscientious objection in such situations.…So, conscientious objection doesn’t make much sense to me because it doesn’t agree with the values of the nursing profession. (N10)

Most participants noted that healthcare professionals should respect patients’ medical decisions.

Having an abortion is the woman’s choice, no one else’s. If a woman chooses to have an abortion, and if we’re like “I don’t want you to have an abortion,” then we are ignoring her right to make a decision about her body. This means that we are challenging her decision, which is something we should never do as healthcare professionals. (N10)

Universal values of nursing

Participants associated the universal values of nursing with ethics (respect for autonomy, justice, beneficence, and non-maleficence), moral values (tolerance, patience, conscience, and compassion), care, holistic approach, and solidarity.

Conscience is derived from one’s moral values and influences moral decision-making processes. The results show that conscience is one of the moral values of nurses^22–24 that is related to CO. ²¹ Conscience is also an essential part of nursing ethics.^24–26

Experiences with Conscientious Objection (refusing to provide care/not providing care)

Participants stated that they may be reluctant to provide healthcare to rapists, terrorists, substance abusers, bedridden patients, AIDS patients, those who were prejudiced against nurses, those who had killed women and children, those who had committed violence against others, and those who had attempted suicide in some situations. On the other hand, the participants also stated that patients’ characteristics cannot be justified for conscientious objection. This result reveals that the participants have their conscience questioned in the face of rejections based on patient characteristics in this study. Nurses may refuse to fulfill some tasks or provide care due to patient characteristics (obese people, addicts, people of different sexual orientations, people with disturbing tattoos, etc.). ²⁷ However, CO due to personal factors, such as prejudices and distaste, is objectionable. ²⁸ Given the core values of nursing, it is unacceptable for nurses to refuse care for patients just because they have AIDS or addiction problems. ²⁹

Participants stated that they had colleagues who did not care or did not want to care for sex workers. Due to their religious beliefs, some nurses prefer to exercise CO to refuse care to women having abortions^4,29–33 and patients of the opposite sex. ³² They also want to exercise that right when patients refuse treatments. ³² For example, The Catholic Church opposes all forms of abortion procedures. Therefore, Catholic healthcare professionals refuse to provide care and treatment to such patients. ³¹ This shows that religious beliefs and teachings determine why and how often healthcare professionals exercise their right to CO. In Turkey, a woman is allowed to have an abortion until the 10th week of pregnancy on the condition that her husband allows it. ³⁴ However, religious beliefs take precedence over law in some situations.

Some nurses do not provide or do not want to provide care to the opposite sex based on their religious beliefs, denying patients their right to care. Although there is no research on CO among Turkish nurses, Keleş et al. ¹⁸ have reported this trend among Turkish medical students and physicians. However, they concluded that medical students and physicians refuse care to the opposite sex because of not only their religious beliefs but also the demands of patients and their family members.

Participants sometimes refused to provide care to the opposite sex because their patients asked them not to due to the sociocultural norms they had been brought up with. Sometimes, they refused to care for the opposite sex because they believed their patients might feel uncomfortable even though they did not explicitly express it. This is especially true for privacy-compromising interventions such as perineal care.

It is crucial to determine whether some nurses refuse to provide care to LGBTIQ+ individuals because of their religious beliefs, personal choices, prejudices against those individuals, or prejudices against the care they are expected to provide. In this study, there were those who wanted to apply conscientious objection on the grounds of gender, but no one gave up or wanted to give up care because of the person’s sexual orientation (such as homosexual). Overall, it is unacceptable for healthcare professionals to refuse to provide care to people due to their sexual orientation or race. ³⁵

Possible effects of conscientious objection

Participants underlined some of the advantages and disadvantages of CO. They believed that CO could help update professional norms, ease nurses’ burden of conscience (refusing to administer CPR to elderly patients or participate in the care of end-stage cancer patients or newborns with anomalies), promote team dynamics, and encourage nurses to respect personal beliefs. Nurses sometimes experience a conflict of conscience when asked to perform tasks that contradict their beliefs and values. ³⁶ If left unresolved, those problems cause moral distress, which adversely affects the working environment.^37,38 Nurses who are forced to perform care interventions that contradict their beliefs and values may experience guilt, sadness, powerlessness, and hopelessness. ¹⁶ This, in turn, negatively affects health outcomes. It is thought that the participants, who emphasized that conscientious objection can be positive in terms of respecting the patients’ personal beliefs and lifestyle, argue that rejection can be effective not because of their own values and beliefs, but based on respect for the dignity of the patients. When evaluated from this point of view, it is thought that they adopt a patient-oriented approach in which the patients’ values are at the forefront.

Some participants believed that CO paves the way for abuse by denying patients their right to care and damaging professional ethics. Participants also thought that nurses who exercised CO might be discriminated against or ostracized. They added that nurses who did not exercise CO might end up working harder than they should because other nurses take refuge in CO and refuse to care for certain patients or implement certain medical interventions because of their beliefs and values. This causes inequality among nurses^28,30,39,40 and puts administrators in a difficult situation.^28,39 Nurses might not speak out about their right to CO if they are unsure about their administrators’ reactions, are afraid of being stigmatized, are scared of losing their job,^15,41 or think they have no right to refuse patients’ demands and physicians’ orders. ¹⁶ Some studies suggest that if nurses turn to CO, it may result in discrimination among patients and denial of access to care.^4,28–30

Scope of conscientious objection

Participants argued that CO was acceptable under certain circumstances. They believed that nurses could exercise CO as long as it was limited (pregnant nurses’ not providing care to patients with infectious diseases, practices other than emergencies, etc.) or the healthcare team agreed on it. They also stated that nurses could exercise CO regarding end-of-life medical decisions (terminal period, futile therapy, euthanasia, etc.), situations that caused moral distress (caring for violent patients, terrorists, rapists, murderers, etc.), and situations that conflicted with their values (abortion, stem cell transplant, gene research, surrogacy, etc.).

It is not surprising that participants expressed their concerns about infectious diseases because we conducted this study during the COVID-19 pandemic. The ANMF explicitly states that “fear, personal convenience or preference, are not sufficient basis for CO.“ ⁴² However, an ethical dilemma is more challenging for pregnant nurses because they are responsible for not only their patients but also their unborn babies. This is probably why participants emphasized that CO should be limited.

Decisions regarding end-of-life care (euthanasia, futile treatment, etc.) are within the scope of CO.^{4,25,29,30,32,39} According to Lanchman, ⁴ a nurse who believes in the sanctity of life can exercise CO, while a nurse who believes in autonomy can take a euthanasia patient off the ventilator to end their life. Nurses can also exercise CO if they think that the treatment they are expected to provide is futile or even harmful. We think that participants advocated CO based on the “beneficence/non-maleficence” ethical values in their profession.

Some nurses exercise CO because they do not want to participate in abortion procedures due to their religious beliefs.^{4,15,29–32,39,43} Heino et al. ³⁰ argue that CO may limit women’s access to abortion or even prevent them from exercising their right to abortion. Nurses also exercise CO when they do not want to participate in stem cell research and genetic tests. ⁴

Nurses believe that they should have the right to refuse to implement medical interventions in situations that may compromise their religious beliefs as long as those situations are not emergencies. ⁴¹ Some authors assert that CO is unacceptable in emergencies.^4,39,44–46

Participants considered CO unacceptable under four circumstances: (1) when healthcare professionals use it as an excuse to refuse care for the opposite sex; (2) when they turn a blind eye to the dynamics of the hospital environment (favoring ideologies and religious beliefs); (3) when they ignore the core values of the profession (discriminating against patients); and (4) when they disregard patients’ medical decisions.

Researchers also argue that CO cannot be based on personal interests, discrimination, and prejudices.^4,40 Our participants stated that nurses should respect women’s decisions on abortion and that CO was unacceptable if it meant ignoring those decisions. However, nurses sometimes consider CO when their patients refuse treatments. ³² These results indicate that nurses consider disrespect for patients’ medical decisions to be unacceptable.

Some authors argue that the legalization of CO may cause inequality among patients and prevent them from exercising their right to healthcare.^29,30,47 The right to act in line with one’s religious and moral values should be limited when it comes to healthcare professionals protecting patient rights. ⁴⁸ Ko et al. ¹² reported that most nurses were of the opinion that patients’ rights took precedence over healthcare professionals’ right to CO. They also found that half of the nurses believed that CO should be legal and that they would not participate in abortion procedures if it was legal. Researchers have concluded that nurses’ willingness to exercise CO shows that they prioritize their religious beliefs and rights. Nurses’ refusal to care for patients because of their religious beliefs, moral values, or ideologies is a very sensitive issue. Therefore, every case should be approached from the perspectives of clinical, ethical, and legal implications, professional obligations, and patient rights. On the other hand, when a patient requests treatment, the nurse can easily explain her decision of CO and may be right in exercising that right.