No pork, please

“I attribute my success to this:—I never gave or took an excuse,” said Florence Nightingale, remembered today as the mother of modern nursing. A Muslim nursing student in Norway did however make some excuses recently, motivated by religious convictions, and the university college put the dilemma to the National Council on Nursing Ethics (NCNE).

While doing a practical training in a nursing home, which is a required component of the Norwegian nursing program, the student had asked to be excused from serving pork or alcohol to patients due to his/her background and religion. The nursing home conceded that it was possible to make such arrangements for the duration of the training period, but said that it would have been difficult to hire a nurse with such demands, and so the university college wondered whether to pass the student or not.

It is hard to say what Nightingale, who was herself a devout woman, would have thought of the predicament, but the NCNE duly discussed and published their response. The council looked at the question from the educational institution’s point of view: would it be unethical to accommodate special requests during training which would be problematic in the student’s future professional career?

The Case for Conscientious Objection

In essence, this is not a novel dilemma for university colleges nationwide who are increasingly encountering a more religiously diverse student mass. From time to time, nursing students request accommodation on grounds of faith such as being able to wear certain clothes, not be in contact with certain foods or not provide intimate care to members of the opposite sex, for example. The students often argue that there are job opportunities for nurses that don’t require them to perform such tasks, or allow them to dress as they wish, and that they should be able to get their degree at their own risk, so to speak, of the troubles that might await them in the job market. To complete the nursing program, however, the students have to pass mandatory practical training in all major sectors where nurses in Norway work.

The National Council on Nursing Ethics made it clear that they consider such reservations to be a breach of professional nursing ethics. They elaborate: “The educational institution cannot train students to practices that collide with the nurse’s professional ethics. The educational institution should also not train anyone to expect a right to reserve oneself that falls outside given rights to reservations. Serving ordinary Norwegian food is not and should not be grounds to claim the right to reservation. Freedom of religion and respect for life stances, in this case Muslim faith, does not encompass serving of food and therefore this is not a relevant argument in this case” [my translation].

The gist of the NCNE’s logic seems to be that providing for the patient comes first – unless a right to conscientious objection has been established. The ethical guidelines for nurses in Norway do in fact contain a reference to the nurse's right to conscientious objections, and that is presumably why the dilemma was addressed to the council in the first place. Its application is contingent on at least two questions to be resolved; on what grounds may conscientious objections be allowed, and at which costs to the patients?

Concerning Beliefs

Let’s start by looking at the first question. Is it enough to be personally convinced, for example as a strict vegetarian, of the immorality involved in serving meat? Legally speaking, employees do not have the right to pick and choose which of their responsibilities they find objectionable and then abstain from those. But what about the individual nurse’s right to freedom of religion, which the NCNE dismissed as irrelevant?

It is always tricky to decide which religious practices and beliefs are central enough to the faith that they are protected by the right to freedom of religion. By issuing regulations that allow certain kinds of religious headwear with health workers’ uniforms, for example, the relevant authorities are in a way recognizing and formalizing a specific practice which may in fact be disputed within the religious community itself. Secular and religious authorities are often equally uncomfortable with the task, yet precedence does exist, as various health institutions have regulated hijab, created prayer spaces or put halal food on the menu for patients and staff. Adversely, in this case it seems clear that the NCNE wishes to draw the line on which religious convictions should be considered relevant by the employer, but not at all clear which authority they have to do so. While public policy is to provide equal services to patients regardless of their religious convictions, how to accommodate for religious diversity among employees is still an ongoing debate.

Pork to the People

Before we look at the second question, which is at what costs to the patients objections of conscience may be tolerate, let’s return again to Florence Nightingale. In her Notes on Nursing: What It Is, and What It Is Not, she writes: “Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Surely the impeccable Nightingale would tolerate no costs to her patients at all, but what if someone else could simply serve the pork, as the student suggested? Or in other terms, if practical accommodations can be made that don’t significantly encumber the patients, should nurses then be allowed objections of conscience?

The idea that the health professional’s objections may rightfully limit service to the patient is not a new idea to the Norwegian public, but surely controversial. In 2013, a deal made by the Christian Conservative party and the ruling government parties to let doctors abstain from giving women abortion referrals started a long-running, heated debate. Already, health personnel may abstain from performing the procedure itself, but this time the proposal concerned the duties of the general practitioners, meaning the doctors every woman seeking abortions would have to face to get her referral. The proposal was seen by many as limiting women’s access to abortion, and protesters swelled the Women’s Day parades to numbers that hadn’t been seen since the 70s. In the end, health minister Bent Høie of the Conservative Party retracted the proposal.

The nuance here is relevant to our case with the nursing student. The line between acceptable objections of conscience was drawn between objections that may be worked around without harm to the patient’s access to the service, as in assigning different doctors to perform abortions, and objections that would affect the patient directly, such as being turned away by your doctor when asking for an abortion. However, sometimes the effects on the patients are not as easy to avoid as one would think. In 2015, when the state controversially ordered public hospitals to offer circumcision of male babies, doctors were simultaneously given the right to abstain from performing the procedure if they objected to the practice. Some six months later, NRK reported that no doctors in Northern Norway were willing to perform the procedure and that patients from this part of the country had to be referred to St. Olav hospital in the mid-country city of Trondheim. The example shows that it can be difficult to achieve equal service to patients when objections of conscience limit what health personnel will do. Still, it seems unlikely that Muslim nurses who won’t touch pork will “take over” nursing homes in Norway in such numbers that patients can’t get their pork chops in a timely manner.

Requirements of the Job

As per usual when these issues are raised, it seems many would rather wish for the whole dilemma to just go away. Some claimed during the abortion referral debate that it was not a "human right" to be a doctor, and that doctors who didn't want to assist women in receiving abortions ought to simply find a new occupation. The logic seems to be that if religiously conservative doctors, police officers or nurses would just choose another occupation, there wouldn’t be any need to discuss the situations where their convictions may collide with their job requirements. As a policy principle, this line would not do much to accommodate minorities, acknowledge the moral dilemmas of health workers, nor provide for more diversity in the Norwegian health service.

Clearly, Nightingale’s principle of self-sacrificing service is not the only ideal to follow in establishing ethical work requirements for nurses. What, then, should become of the Muslim nursing student who wouldn’t serve pork? It is fairly easy to fail a nursing student still in training, compared to firing doctors from their jobs because of a policy change, but is it right? Most of those commenting on the case in the media, including both gender and equality ombud Hanne Bjurstrøm and the board director of one of Oslo’s biggest mosques, conclude that such dilemmas should not be treated categorically, but resolved in the work place. It remains a moral conundrum for the educational institutions, then, whether to pass someone who could be accommodated once but perhaps not always.