The Place of Conscience in The Place of Conscience in Healthcare Practice Healthcare Practice

Jerome R. Wernow Ph.D., R.Ph.Jerome R. Wernow Ph.D., R.Ph.NW Center for BioethicsNW Center for Bioethics

www.ncbioethics.orgwww.ncbioethics.org

Conscience UseConscience Use

ObjectivesObjectives

History behind socio-cultural difference History behind socio-cultural difference that commonly lead to social and ethical that commonly lead to social and ethical tensions tensions

Understand the terminology used in the Understand the terminology used in the conscience clause discussionconscience clause discussion

Conflict management with patients, Conflict management with patients, employers, employees, or advocacy employers, employees, or advocacy groupsgroups

Take Home Points Take Home Points

Disclosure that is well thought outDisclosure that is well thought out Disclosure that is legally informedDisclosure that is legally informed Disclosure that is timely and conciseDisclosure that is timely and concise Disclosure that is authenticDisclosure that is authentic Disclosure that avoids moralizingDisclosure that avoids moralizing Disclosure that assures patient careDisclosure that assures patient care

Well thought out: ClarificationWell thought out: Clarification

ScopeScope TermsTerms

Scope of Conscientious Objection Scope of Conscientious Objection

Abortion Abortion EuthanasiaEuthanasia Assisted suicideAssisted suicide Fetal and stem cell therapyFetal and stem cell therapy Sterilization Sterilization

Religious Refusals and Reproductive Rights-ACLU Reproductive Freedom Project 2002, Weiss, Catherine, Caitlin Borgmann, and Louise Melling et al: <http://www.aclu.org/FilesPDFs/ACF911.pdf> p. 21

Scope Limits in PresentationScope Limits in Presentation

““Plan B contraception” Plan B contraception” Meaning: large doses of estrogen and Meaning: large doses of estrogen and

levonorgestrel or a progestin congener in levonorgestrel or a progestin congener in one or two doses to prevent pregnancyone or two doses to prevent pregnancy

Litmus test due to time-related urgency of Litmus test due to time-related urgency of medication administration medication administration

Mechanism of ActionMechanism of Action

(1) primarily prevents or delays ovulation(1) primarily prevents or delays ovulation

(2) Interferes with tubal transport of sperm, (2) Interferes with tubal transport of sperm,

(3) interferes with fertilization(3) interferes with fertilization

(4) possibly prevents implantation of the (4) possibly prevents implantation of the fertilized egg fertilized egg

Kathleen Besinque: “Emergency Contraception,” in Drug Topics. February 20, 2006, p. 7 <http://images.digiscript.com.edgesuite.net /a/21000/21949/21949-1743964.pdf?obj=v1> Last visited: January 27, 2007.

Pluralism in ObjectionPluralism in Objection

Roman Catholic teaching of the Church Roman Catholic teaching of the Church objects on basis of all four mechanismsobjects on basis of all four mechanisms

Pro-life protestants usually object only the Pro-life protestants usually object only the basis of the fourth mechanismbasis of the fourth mechanism

Clarification of TermsClarification of Terms

‘‘Conscience Clause’ Conscience Clause’ ≠≠ ‘Refusal Clause’‘Refusal Clause’

Conscience ClauseConscience Clause

““an innate moral character an innate moral character expressed in an objective moral expressed in an objective moral confession that responds to a confession that responds to a

morally challenging circumstance” morally challenging circumstance”

Charles E. Curran, ed., Conscience, in Readings in Moral Theology Series no.14. (New York∙Mahwah, NJ: Paulist Press, 2004) pp. 3-38.

A View ConscienceA View Conscience

A Christianized Franklian View: Frankl, Victor: The Unconscious God. (New York: Washington Square Books, 1985) p. 29.

Conscious

Subconscious

Pre-conscious

Corporeality

Spiritual Illumination

Psychofacticity

Refusal ClauseRefusal Clause

““a law that allows entities and/or a law that allows entities and/or individuals to refuse to provide or cover individuals to refuse to provide or cover

certain health services based on certain health services based on religious or moral objections.” religious or moral objections.”

ACLU Reproductive Freedom Project 2002, p. 6.

Mythos Mythos and and LogosLogos

Mythos Mythos describes “worldly things by describes “worldly things by tracing them to exceptional, sometimes tracing them to exceptional, sometimes sacred events, that caused the world to be sacred events, that caused the world to be as it is now.” as it is now.”

Logos Logos “a kind of logical analysis that “a kind of logical analysis that places things in the context of reason and places things in the context of reason and explains them with the pure force of explains them with the pure force of thought.”thought.”

Palmer, Donald: Looking at Philosophy: The Unbearable Heaviness of Philosophy Made Lighter. (Mountain View, CA: Mayfield Publishing) second edition, 1994, p. 2.

Mythos Mythos and and LogosLogos

““There are other accounts, however, There are other accounts, however, accounts that suggest that Western accounts that suggest that Western

Logos-Logos-philosophy and science is just philosophy and science is just our version of our version of mythosmythos.” .”

Palmer, Donald: Looking at Philosophy: The Unbearable Heaviness of Philosophy Made Lighter. (Mountain View, CA: Mayfield Publishing) second edition, 1994, p. 2.

Short History behind Short History behind Socio-cultural DifferenceSocio-cultural Difference

MythosMythos Hippocrates (460-347 Hippocrates (460-347

BC)BC) Scribonius Largus (47 Scribonius Largus (47

AD)AD) C. Galenus (129-201 AD)C. Galenus (129-201 AD) Church Fathers (330 AD)Church Fathers (330 AD) Quiescent Period*Quiescent Period* American Medical American Medical

Association in 1847Association in 1847

LogosLogos Plato (460-347 BC)Plato (460-347 BC) Soranus (47 AD)Soranus (47 AD) Marquis de Sade 1740-Marquis de Sade 1740-

1814 AD1814 AD Post-Christian EpochPost-Christian Epoch

*Edmund D. Pellegrino: “The Metamorphosis of Medical Ethics,” The Journal of the American Medical Association. v. 269/9 (March 3, 1993) pp. 1158-1162.

Changes behind public acceptance Changes behind public acceptance of contraception and abortifacients of contraception and abortifacients

Drug effectivenessDrug effectiveness WorldviewWorldview EpistemologyEpistemology Ethics Ethics Socio-political factorsSocio-political factors

Metamorphosis in Drug Metamorphosis in Drug EffectivenessEffectiveness

Development and Development and release of Enovidrelease of Enovid

((June 23, 1960June 23, 1960 ) )

“unfettered…from the beginning woman has been a vassal to temporal demands–and frequently the aberrations–of cyclic mechanisms of her reproductive system. Now to a degree heretofore unknown, she is permitted normalization, enhancement or suspension of cyclic function and procreative potentia” S.W, Junod and L . Marks: "The first oral contraceptive pill.” p. 128-129.

Metamorphosis in WorldviewMetamorphosis in Worldview

‘‘enlightenment philosophy and rationality enlightenment philosophy and rationality leavened the bread of moral philosophy in the leavened the bread of moral philosophy in the

medical schools, studies in humanist medical schools, studies in humanist psychology began to be substituted for psychology began to be substituted for

Christian ethics’ Christian ethics’

op cit : Chester R. Burns, “American Ethics: Some Historical Roots”

Metamorphosis in EpistemologyMetamorphosis in Epistemology

Judeo-Christian Hippocratic ethic dominant seventeen Judeo-Christian Hippocratic ethic dominant seventeen centuries dominant explaining how things exist sourced centuries dominant explaining how things exist sourced in the Biblical interpretationsin the Biblical interpretations

Modernity’s early epistemological drift embraced mutual Modernity’s early epistemological drift embraced mutual influence of Christian theology and scientific belief influence of Christian theology and scientific belief

John Locke introduced split empirical knowledge from John Locke introduced split empirical knowledge from that of the world of faith that of the world of faith

Drift became a torrent from atheists David Hume to Drift became a torrent from atheists David Hume to Richard Dawkins to Samuel HarrisRichard Dawkins to Samuel Harris

Evolutionary materialism became dominant explaining Evolutionary materialism became dominant explaining what exists through empirical observation of the material what exists through empirical observation of the material worldworld

The Ethics of Power The Ethics of Power

"Not the Church, not the State"Not the Church, not the State—Women will decide our fate.”—Women will decide our fate.”

Pat Ruess and Jan Erickson, “Access for All? Reclaiming Women's Contraceptive Options one Pharmacy at a Time,” <http://www.now.org/issues/reproductive/ec_action_plan.html> Last visited January 20, 2007

Socio-cultural differenceSocio-cultural difference

Those who construct the meanings of reality Those who construct the meanings of reality through stories about the material world through stories about the material world

alone -- contrasted to those who construct alone -- contrasted to those who construct meanings of reality through stories about the meanings of reality through stories about the

material world along with stories about material world along with stories about realities that transcend that world.realities that transcend that world.

Conflict ManagementConflict Management

Conflict is sourced in differing worldview Conflict is sourced in differing worldview commitments that give meaning to the commitments that give meaning to the perceived rights and actualization of the perceived rights and actualization of the individuals.individuals.

Judeo-Christian Worldview Judeo-Christian Worldview

Reality, meaning, and practice Reality, meaning, and practice gains moral clarity primarily gains moral clarity primarily

through narratives is derived from through narratives is derived from a supernatural source, their Bible. a supernatural source, their Bible.

Paula Koch: an examplePaula Koch: an example

Discovered morning after pill dispensed Discovered morning after pill dispensed eighteen months before her initial eighteen months before her initial confrontationconfrontation

Informed by passages like Psalm 139, Informed by passages like Psalm 139, Genesis 1:27, and Exodus 20:3 Genesis 1:27, and Exodus 20:3

Based sanctity of life principle as found in Based sanctity of life principle as found in Donum Vitae Donum Vitae

Donum Vitae, 5Donum Vitae, 5

““God alone is the Lord of life from its beginning God alone is the Lord of life from its beginning until its end: no one can under any circumstance until its end: no one can under any circumstance claim for himself the right directly to destroy an claim for himself the right directly to destroy an

innocent human being” innocent human being”

Pope John Paul II: Donum Vita 5 http://www.nccbuscc.org/prolife/ tdocs/introduction.htm Last visited October 24, 2007.

Evolutionary Natural Evolutionary Natural Materialism Materialism

Reality, meaning, and practice Reality, meaning, and practice gain moral clarity is primarily from gain moral clarity is primarily from

narratives derived from human narratives derived from human reason and experience. reason and experience.

Protagonists of Reproductive Protagonists of Reproductive AccessAccess

NARAL - positive right (reason)NARAL - positive right (reason) ACLU (Dershowitz) - majoritarian preference ACLU (Dershowitz) - majoritarian preference

(human experience)(human experience)

Positive RightPositive Right

““If 'A' has a positive right against If 'A' has a positive right against 'B', then 'B' must assist 'A' to do 'x' 'B', then 'B' must assist 'A' to do 'x'

if 'A' is not able to do 'x' without if 'A' is not able to do 'x' without that assistance” (wiki)that assistance” (wiki)

Majoritarian PreferenceMajoritarian Preference

““right” that derives from the right” that derives from the ‘majorities’ current experience of ‘majorities’ current experience of

“grievous injustice whose “grievous injustice whose recurrence we seek to prevent.”recurrence we seek to prevent.”

Dershowitz, Alan: Rights from Wrongs: a Secular Theory of the Origins of Rights. (New York, Basic Books, 2004) pp. 82, 90

Disclosure that is legally informedDisclosure that is legally informed

National ConscienceNational Conscience States of ConscienceStates of Conscience

Legal History and Federal LawsLegal History and Federal Laws

Generated from US Supreme Court’s 1973 Generated from US Supreme Court’s 1973 decision in decision in Roe v. WadeRoe v. Wade

Jody Feder: “The History and Effect of Abortion Conscience Clause Laws,” in CRS Report for Congress. CRS-2. < http://www.law.umaryland.edu/ marshall/crsreports/crsdocuments /RS2142801142005.pdf > Last visited: November 12, 2007

Church Amendment 1973Church Amendment 1973

Allowed health care professionals to opt Allowed health care professionals to opt out of procedures involving sterilization or out of procedures involving sterilization or abortion procedures to which they had abortion procedures to which they had moral or ethical objections in institutions moral or ethical objections in institutions which received federal funding. which received federal funding.

Balanced Budget Act of 1997Balanced Budget Act of 1997

““permitted managed care organizations to permitted managed care organizations to opt out of “provid[ing], reimburs[ing] for, or opt out of “provid[ing], reimburs[ing] for, or provid[ing] coverage of, counseling or provid[ing] coverage of, counseling or referral service if the organization objects referral service if the organization objects to the service on moral or religious to the service on moral or religious grounds.”grounds.”

42 U.S.C. Section 1396u-(b)(3)(B)(ii)(2000). See also 42 C.F.R. Section 438.102(a)(2)(2002).

Abortion Non-Discrimination Abortion Non-Discrimination Act (ANDA) 2002Act (ANDA) 2002

Allows providers “or any other kind of health care facility, Allows providers “or any other kind of health care facility, organization or plan to opt out of performing, providing organization or plan to opt out of performing, providing coverage of, or paying or making referrals for induced coverage of, or paying or making referrals for induced abortions, without exception to save the life or health of the abortions, without exception to save the life or health of the mother or for cases of rape or incest.” mother or for cases of rape or incest.”

American Bar Association Section on Individual Rights and Responsibilities, Report to the House of Delegates, at 7 (2004). www.abanet.org/leadership/ 2004/annual/119.doc Last visited: November 12, 2007

Hyde-Weldon AmendmentHyde-Weldon Amendment

(1) None of the funds made available in this Act [the (1) None of the funds made available in this Act [the federal Health and Human Services appropriations bill for federal Health and Human Services appropriations bill for Fiscal Year 2005] may be made available to a Federal Fiscal Year 2005] may be made available to a Federal agency or program, or to a State or local government, if agency or program, or to a State or local government, if such agency, program, or government subjects any such agency, program, or government subjects any institutional or individual health care entity to institutional or individual health care entity to discrimination on the basis that the health care entity discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for does not provide, pay for, provide coverage of, or refer for abortions. abortions.

Title VII of the Civil Rights Act Title VII of the Civil Rights Act of 1964of 1964

SEC. 2000e-2. SEC. 2000e-2. [Section 703] [Section 703] (a) It shall be an unlawful (a) It shall be an unlawful employment practice for an employer - (1) to fail or refuse employment practice for an employer - (1) to fail or refuse to hire or to discharge any individual, or otherwise to to hire or to discharge any individual, or otherwise to discriminate against any individual with respect to his discriminate against any individual with respect to his compensation, terms, conditions, or privileges of compensation, terms, conditions, or privileges of employment, because of such individual's race, color, employment, because of such individual's race, color, religion, sex, or national origin; or religion, sex, or national origin; or

AMA Position StatementAMA Position Statement

(2) no physician of other professional personnel shall be (2) no physician of other professional personnel shall be required to perform an act violative of good medical required to perform an act violative of good medical judgment. Neither physician, hospital, nor hospital judgment. Neither physician, hospital, nor hospital personnel shall be required to perform any act violative of personnel shall be required to perform any act violative of personally held moral principles. In these circumstances, personally held moral principles. In these circumstances, good medical practice requires only that the physician or good medical practice requires only that the physician or other professional withdraw from the case, so long as the other professional withdraw from the case, so long as the withdrawal is consistent with good medical practice. withdrawal is consistent with good medical practice.

H-5.995 Abortion, House of Delegates (2)

Oregon State Statute: Oregon State Statute: Unprofessional ConductUnprofessional Conduct

““any conduct or practice which any conduct or practice which does or might constitute a danger does or might constitute a danger to the health or safety of a patient” to the health or safety of a patient” 677.188 (4) a 677.188 (4) a

Legal Conflicts UnivocalLegal Conflicts Univocal

Litigation is strictly against health Litigation is strictly against health care professionals who can be care professionals who can be

classified as practicing Christiansclassified as practicing Christians

Why Look at Pharmacy?Why Look at Pharmacy?

Principle of reproductive access held by Principle of reproductive access held by litigants applies to practice of all health litigants applies to practice of all health care professionalscare professionals

Defendants predicate their positions on Defendants predicate their positions on commonly held principlescommonly held principles

Pharmacy case law applied to litigation Pharmacy case law applied to litigation against other health care professionalsagainst other health care professionals

Litigation SampleLitigation Sample

Karen Brauer v K-MartKaren Brauer v K-Mart Case of Paula KochCase of Paula Koch Neil Noesen v State of Wisconsin Neil Noesen v State of Wisconsin

Pharmacy BoardPharmacy Board Ethan Vandersand v Wal-MartEthan Vandersand v Wal-Mart Stormans v Washington State Board of Stormans v Washington State Board of

PharmacyPharmacy

Noesen v State of Wisconsin Noesen v State of Wisconsin Pharmacy BoardPharmacy Board

Notified and fully disclosed to contractor K-Notified and fully disclosed to contractor K-Mart’, of conscientious objection “to participating Mart’, of conscientious objection “to participating in the work of contraception.”in the work of contraception.”

Arranged alternative at site but not in writingArranged alternative at site but not in writing Refused to refill and declined to transferRefused to refill and declined to transfer Perceived by patient and employees as Perceived by patient and employees as

belligerentbelligerent

Immediate Material Immediate Material CooperationCooperation

Immediate material cooperation occurs when the Immediate material cooperation occurs when the cooperator participates in circumstances that are cooperator participates in circumstances that are essential to the commission of an act, such that the essential to the commission of an act, such that the act could not occur without this participation. act could not occur without this participation. Immediate material cooperation in intrinsically evil Immediate material cooperation in intrinsically evil actions is morally illicit. actions is morally illicit.

http://www.ascensionhealth.org/ethics/public/key_principles/cooperation.asp

Ruling against NoesenRuling against Noesen

(1)(1) failed to inform his employer that he failed to inform his employer that he would not transfer a prescription for oral would not transfer a prescription for oral contraceptives based upon his contraceptives based upon his conscientious objectionconscientious objection

(2)(2) by failed to provide the patient with by failed to provide the patient with information pertaining to her options for information pertaining to her options for obtaining a refill of her prescriptions. obtaining a refill of her prescriptions.

Judge Baird’s RulingJudge Baird’s Ruling

““the standard of care ordinarily exercised by a pharmacist the standard of care ordinarily exercised by a pharmacist requires that a pharmacist who exercises a conscientious requires that a pharmacist who exercises a conscientious objection to the dispensing of a prescription must ensure objection to the dispensing of a prescription must ensure that there is an alternative mechanism for the patient to that there is an alternative mechanism for the patient to

receive his or her medication including informing the patient receive his or her medication including informing the patient of their [sic] options to obtain their prescription. of their [sic] options to obtain their prescription.

Findings of Fact no. 54 http://drl.wi.gov/dept/decisions/docs/0405070.htm . Last visited October 24, 2007.

Noesen v MSNNoesen v MSN

Allegations he simply walked away from Allegations he simply walked away from customers or left them on hold indefinitelycustomers or left them on hold indefinitely

Law enforcement forcibly removed Law enforcement forcibly removed Noesen from the store by duct taping him Noesen from the store by duct taping him to a wheel chair after he refused to leave to a wheel chair after he refused to leave storestore

Title VII of the Civil Rights Act of 1964 Title VII of the Civil Rights Act of 1964

District Judge John C. Shabaz District Judge John C. Shabaz RulingRuling

““Wal-Mart gave [Noesen] the exact Wal-Mart gave [Noesen] the exact accommodation he sought”; that is, not “to accommodation he sought”; that is, not “to transfer, refer, renew, dispense, verify or transfer, refer, renew, dispense, verify or touch prescriptions for birth control.” touch prescriptions for birth control.”

““not entitled to an additional not entitled to an additional accommodation under the law” accommodation under the law”

Neil T. Noesen v. Medical Staffing Network, Inc., et al., United States District Court for the Western District of Wisconsin (Cause No. 06-C-

071-S), June 1, 2006.

Stormans v Washington State Stormans v Washington State Board of PharmacyBoard of Pharmacy

Plaintiff Rhonda Mesler will be fired from her position as pharmacy manager because her employer cannot afford to hire another pharmacist to work with herto comply with 246-869-010.3

Storman’s Stores and the pharmacy manager were investigated by the Board for allegedly failing to maintain an adequate stock of “Plan B”

Stormans v Washington State Stormans v Washington State Board of PharmacyBoard of Pharmacy

Equal Protection Violation Equal Protection Violation Supremacy Clause Violation Supremacy Clause Violation Free Exercise Violation Free Exercise Violation Procedural Due Process Violation Procedural Due Process Violation

Equal Protection Violation Equal Protection Violation

Selective enforcement by the Human Rights Selective enforcement by the Human Rights Commission & Board of Pharmacy against Commission & Board of Pharmacy against

single v multiple Rx employmentsingle v multiple Rx employment

Supremacy Clause ViolationSupremacy Clause Violation

““Desire relief from government coercion that Desire relief from government coercion that would deny them an “unalienable right of would deny them an “unalienable right of conscience on matters of religious and moral conscience on matters of religious and moral conviction” conviction”

Free Exercise ViolationFree Exercise Violation

““the Rules and Commission make the Rules and Commission make them “choose between their livelihoods them “choose between their livelihoods

as health care providers and their as health care providers and their exercise of religion” exercise of religion”

Procedural Due Process Procedural Due Process ViolationViolation

““allegation is that the Human Rights Commission coerced allegation is that the Human Rights Commission coerced the Board of Pharmacy to adopt the regulations which the Board of Pharmacy to adopt the regulations which effectively eliminate the pharmacists’ right to conscience effectively eliminate the pharmacists’ right to conscience and their liberty and property interests and livelihoods, and their liberty and property interests and livelihoods, secured by the Due Process Clause of the United States secured by the Due Process Clause of the United States Constitution”Constitution”

Preliminary injunction grantedPreliminary injunction granted

““the overriding objective of the subject regulations the overriding objective of the subject regulations was, to the decree possible, to eliminate moral and was, to the decree possible, to eliminate moral and religious objections from the business of dispensing religious objections from the business of dispensing medication” which created a “Hobson’s choice for medication” which created a “Hobson’s choice for the majority of pharmacists who object to Plan B: the majority of pharmacists who object to Plan B: dispense a drug that ends a life as defined by their dispense a drug that ends a life as defined by their religious teachings, or leave their present position in religious teachings, or leave their present position in the State of Washington.” the State of Washington.”

Stormans Incorporated, et al. v. Selecky, et al.: U. S. District Court for Western District of Washington No. 07-cv-05374-RBL: “Order Granting Preliminary Injunction,” November 8, 2007, p. 16. U. S. District Judge Ronald Leighton

Hobson’s ChoiceHobson’s Choice

"Where to elect there is but one, / "Where to elect there is but one, / 'Tis Hobson's choice—take that, 'Tis Hobson's choice—take that,

or none." Ward 1688or none." Ward 1688

Principle of AutonomyPrinciple of Autonomy

A woman’s reproductive self-determination A woman’s reproductive self-determination through access to emergency through access to emergency contraceptives contradicted a health care contraceptives contradicted a health care providers self-determination to exercise providers self-determination to exercise religious conscience religious conscience

Not resolvable without violation of Not resolvable without violation of autonomyautonomy

RightsRights

Current socio-cultural norm of women’s Current socio-cultural norm of women’s rights and gender equality conflicts against rights and gender equality conflicts against rights of religious freedom rights of religious freedom

Renders resolution by appeal to ‘rights’ Renders resolution by appeal to ‘rights’ insuperable even though both parties insuperable even though both parties recognize ‘rights’ as a human construct recognize ‘rights’ as a human construct

Antecedent meta-ethical Antecedent meta-ethical commitmentscommitments

Conflict sourced in differing worldview Conflict sourced in differing worldview commitments that give meaning to commitments that give meaning to the perceived rights and actualization the perceived rights and actualization of the individualsof the individuals

Conflict ManagementConflict Management

Conflict sourced in differing worldview Conflict sourced in differing worldview commitments that give meaning to the commitments that give meaning to the perceived rights and actualization of the perceived rights and actualization of the individualsindividuals

ProtagonistsProtagonists

Reality, meaning, and practice Reality, meaning, and practice gains moral clarity primarily gains moral clarity primarily

through narratives derived from a through narratives derived from a supernatural source, their Bible.supernatural source, their Bible.

AntagonistsAntagonists

Reality, meaning, and practice Reality, meaning, and practice gain moral clarity primarily from gain moral clarity primarily from narratives derived from human narratives derived from human

reason and experience.reason and experience.

Take Home Points Take Home Points

Disclosure that is well thought outDisclosure that is well thought out Disclosure that is legally informedDisclosure that is legally informed Disclosure that is timely, concise, and Disclosure that is timely, concise, and

documenteddocumented Disclosure that is courteousDisclosure that is courteous Disclosure that avoids moralizingDisclosure that avoids moralizing Disclosure that assures patient careDisclosure that assures patient care