In today’s healthcare, certain treatments such as abortion procedures or palliative sedation can raise ethical concerns for health professionals asked to engage in them. The ethical concerns can emerge from health professionals’ own ethical and moral values, patients’ needs or wishes, or treatments’ potential risk for harm., and can be viewed differently depending on the cultural circumstances.

Health professionals’ ethical and moral values are shaped by professional codes of ethics  and health standards as well as influencing, for example, consequentialistic theories such as Utilitarianism. Additionally, organizations also have their own standards concerning certain treatments. Also, health professionals are shaped by their own personal ethical and moral values. Familial environment and education or national values or culture of the country of residence and/or origin, all and more sources influence the individual (Grace et al., 2023; Zumstein-Shaha et al., 2025). 

Health professionals are required to assess patients’ needs systematically and elicit their wishes, particularly in crisis situations and/or for the beginning or end of life. For this, health professionals – particularly nurses – are trained in conducting assessments and discussing personal wishes. To date, dramatic personnel shortages, increasing numbers of patients with complex chronic and/or multiple disease, advances in technology and innovation, and soaring health care costs put health professionals – in particular nurses – under severe constraints to complete their work faithfully and adequately. Therefore, it is possible that patients’ needs and wishes may not be elicited in a proper manner, there may not be sufficient time to address these elements fully, or the necessary personnel and/or conditions are missing (Grace et al., 2023; Zumstein-Shaha et al., 2025). 

Technological advances and innovations in medicine and other related fields propose treatments with the potential for positive health outcomes for patients. Some treatments can be rigorous with potentially gruesome side-effects, or can lead to immediate death in case of system failure, or even have to be turned off intentionally, leading to death. Other treatments may be advertised as providing relief, which eventually does not manifest. Again other treatments may require patients to faithfully adhere to a difficult and strict regime. If not, the risk for detrimental effects become probable. Often, the family who act as caregivers are thrown into these situations with limited adequate preparation. Overall, despite exciting possibilities, and good outcomes, there are high risks and dangers associated with such circumstances (Zumstein-Shaha et al., 2025). 

When health professionals find themselves in ethically and morally challenging situations, there are several courses of action, per se or combined. Health professionals can carry on as usual, engage in work-arounds or deviance. Other health professionals may develop distress, fall ill or leave their jobs. Others chose to object conscientiously.  (Grace et al., 2023). 

The notion of conscientious objection inspired a group of nurse ethicists to develop a framework entitled “Ethical Evaluation of a Nurse’s Conscientious Objection (EENCO)” (Grace et al., 2023). The framework is structured along Rest’s four components, namely ‘moral sensitivity’, ‘moral judgment’, ‘moral motivation’, and ‘moral character’. Each component was then enhanced with questions for persons expressing conscientious objection, and for evaluators. Application of this framework was demonstrated along two cases, namely palliative sedation and nurses working around strict organizational rules during Covid-19 (Zumstein-Shaha et al., 2025). 

While discussing the application of the EENCO framework, cultural differences to conscientious objection seemed to emerge. Where nurses and other health professionals in the United States of America appear to openly object and maintain their stance, hardly any such cases were found in Switzerland (Mader et al., 2002). However, work-arounds and deviance seemed to be more prevalent in Swiss health care settings. The question of conscientious objection on Switzerland was explored at national level around 2000, highlighting the paucity of evidence on this issue (Mader et al., 2002). It was pointed out that legally every health professional in Switzerland could cite irreconcilable differences and refrain from participating in certain practices on the ground of infringement of personal ethical and moral values and beliefs, as the Swiss legal system was found to provide sufficient means to guarantee individual rights and to consider institutional and public rights adequately (Mader et al., 2002). In the early 2000, Switzerland adopted legal abortion. Since then, no major case of conscientious objection even in the face of late abortion has emerged. It was found that objectors could continue to work but did not have to participate in practices considered morally harmful to themselves (Nationale Ethikkommission Schweiz, 2018). 

In summary, it was found that ethical issues can be viewed differently depending on the circumstances. Only ethical discussions of various persons with varied scientific backgrounds but a strong commitment to nursing ethics allowed for this discovery. 

Resources

Grace, P. J., Peter, E., Lachman, V. D., Johnson, N. L., Kenny, D. J., & Wocial, L. D. (2023, 2024/05/01). Professional responsibility, nurses, and conscientious objection: A framework for ethical evaluation. Nursing Ethics, 31(2-3), 243–255. https://doi.org/10.1177/09697330231180749

Mader, L., Baumann-Hölzle, R., Gabathuler, U., Kuhn, H., Küttel, E., Leuthold, M., Schuler, T., Sprumont, D., Wagner, P.-A., Trösch, A., Brunner, N., Grob, U., Moser-Szeless, M., Roncoroni, G., & Schöbi, F. (2002). Zur Problematik der Verweigerung einer Mitwirkung bei medizinischen Behandlungen aus Gewissensgründen (Arbeitsgruppe Rechte des medizinischen Personals, Issue. EJPD. https://www.newsd.admin.ch/newsd/message/attachments/75661.pdf

Nationale Ethikkommission Schweiz. (2018). Zur Praxis des Abbruchs im späteren Verlauf der Schwangerschaft Ethische Erwägungen und Empfehlungen https://www.nek-cne.admin.ch/inhalte/Themen/Stellungnahmen/NEK_Stellungnahme_Abbruch_im_spaeteren_Verlauf_der_Schwangerschaft_D.pdf

Zumstein-Shaha, M., Wocial, L. D., Lachman, V. D., Johnson, N. L., Rushton, C. H., & Grace, P. J. (2025). Evaluating Nurse Conscientious Objection: Application of a Novel Framework. HEC Forum. https://doi.org/10.1007/s10730-025-09556-7

Dr. Maya Zumstein-Shaha is Deputy Head of the Master of Science in Nursing Program at the Bern University of Applied Sciences, School of Health Professions, in Bern, Switzerland. She is a member of the SONEI Steering Committee.