Table 1: Examples of clinical situations that may result in ethical tension or conscientious refusal.


(i) Government pressures physician to perform punitive amputationOrthopedic surgeon told by Afghani government officials to amputate a healthy man’s leg as a punishment for theft [13].
(ii) Physician pressured to perform CPRIn a case situation consistently deemed medically futile, a clinician refuses to prolong dying, squander resources, and extend patient suffering by repeatedly commencing CPR [14].
(iii) Peer pressure for physician to conform to standard of care guidelinesA doctor is derided for using evidence-based nutritional and environmental interventions where such therapies deviate from standard clinical practice [15, 16].
(iv) Patient requests physician to complete paperwork so parents can travel for cultural ceremonyParent requests official approval from a physician for their daughter to travel to Africa in order to undergo a ritual female genital mutilation ceremony [17].
(v) Physician asked for advice about suitability of abortion Patients seek advice from a rural physician on suitability and wisdom of having an abortion after discovering that the developing fetus has cystic fibrosis [18].
(vi) Physician asked to determine fetal genderRequest that the physician determine fetal gender at 12 weeks gestation with the expressed aim of choosing female feticide if the fetus is not male [19].
(vii) Patient request for assisted suicide An elderly patient adamantly requests that a physician prescribe a lethal dose of sedation [20].
(viii) Peer pressure to increase hospital efficiency at the cost of patient care A physician is unable to provide optimal care for seniors with severe dementia as a result of explicit institutional economic constraints [21].
(ix) Young patient requests tubal ligationFollowing the delivery of a stillborn child, a 19 year old with no live children determinedly requests an irreversible tubal ligation procedure [22].
(x) Patient request for genital reconstructionAdult female requests a re-infibulation procedure (reconstruction of ceremonially cut female genitalia) following vaginal childbirth [23, 24].
(xi) Patient demands narcotic analgesiaPhysician is suspicious of narcotic abuse with the patient [25].
(xii) Parents of child refuse consent for life-saving blood transfusionPhysician considers legal measures to save the life of the child through blood replacement [26].
(xiii) Parents of young woman request virginity certificateBased on personal moral beliefs, the clinician refuses to exam the hymen of the young woman-despite explicit consent from the young woman herself.
(xiv) Patient demands respect for personal autonomy in choice of physicianA pregnant woman refuses emergency obstetrical care based on the clinician’s gender and race. She demands referral to a female physician.
(xv) Patient requests distortion of truthA terrified immigrant woman implores her family physician to lie to her husband regarding the nature of a previous surreptitious medical visit.