CONSCIENTIOUS OBJECTION IN SPANISH PODIATRISTS STUDENTS : A QUESTIONNAIRE SURVEY

Objective: To explore attitudes towards conscientious objections among podiatrists students in Spain. Methods: Podiatrists students at University of A Coruña, King Rey Juan Carlos University, University of Sevilla and Complutense University of Madrid were emailed a link to complete an anonymous online questionnaire, hosted by an online survey company. A total of 432 podiatrists students responded. Results: Nearly half of the students in this survey stated that they believed in the right of podiatrist to conscientiously object to any procedure. Demand for the right to conscientiously object is greater in Roman Catholic podiatrists students when compared with other groups of religious podiatrists students. Discussion: Examining patients and podiatric treatments continues to be controversy issues among podiatrists students and this may contribute to the looming crisis in podiatry services over next years. This project sheds some light on how future podiatrist view some of their ethical rights and obligations. Using empirical evidence, it reveals that conscientious objection is an issue in the Spain podiatrists student body today. These data could help anticipate problems that may arise when these podiatrists students qualify and practice podiatry in the community. Conclusion: Clearer guidance is needed for podiatrists students about the issue of conscientious objection at podiatry school.


Introduction
The podiatric profession is fraught with ethical dilemmas, shortage of resources, problems of organization and lack of strategies to face these ethical dilemmas (1).In Spain the increase of enquiries from podiatry students and podiatrists related to the search for answers on how to balance their personal beliefs with their professional activity, has encourage the General Board of Podiatrists' Official Associations (GBPOA) to publish a Code of Ethics.In this Code the right to freedom of expression for the students of podiatry and the podiatrists is recognized, but, in article 1, it is stated that 7 "The Podiatrists in his/her professional activity will respect scrupulously the persons' right to freedom, dignity and intimacy.The patient should not be discriminated against because of his/her race, sex, religion, political ideas and any other condition".Also, in the paragraph 8, it is stated that: "The collegiate members that infringe the professional duties related in this Podiatry Code of Practice or those related in any other Association one, could be subjected to disciplinary punishment according to its articles"(2).
In spite of the publicity, there are few empirical studies on the topic of conscientious objection in medicine.Also studies on podiatry students and podiatrists are not known.In 2012, Strickland polled United Kingdom medical students to explore their attitudes towards conscientious objection when performing different procedures in their healthcare activity(3).
In 2014, Nordstrand et al. surveyed medical students to examine their beliefs on conscientious objection and the controversy in medical procedures(4).Following Card, reasonable exemptions and alternative curricular activities should be provided to the students in order to learn the required content and the underlying principles (5).
The idea of this study emerged as a consequence of the refusal of some podiatry students and podiatrists to learn about procedures invoking conscientious objection (6).This paper presents the findings of a study on conscientious objection among podiatrists students in Spain.

Participants
A total of 850 podiatrists students at University of La Corunna, University of Seville, King Rey Juan Carlos University and Complutense University of Madrid were invited to take part in the study sending an anonymous e-mail.

Questionnaire
Students were invited to complete an anonymous online questionnaire on conscientious objection.Previous invitation emails ware sent by Google Docs (7) website from June 1 and October 31, 2014.
In total, the questionnaire contained five questions, addressing podiatry students' opinions towards conscientious objection and attitudes towards a series of procedures.The questions were addressed to topical areas of healthcare and the possibility of conflict with their religious, moral or personal beliefs, including abortion, euthanasia, the treatment of patients intoxicated with alcohol or recreational drugs, the examination of a person of the opposite sex, and the care of persons with scarce economic resources.
The questionnaire and the study were checked by the Committee of Ethics and Investigation of the University of a Coruña, Spain.It was assigned the registration number CE 16/2014.All participants signed an informed consent form before being included in the study.The WMA (Medical World Assembly) Declaration of Helsinki -Ethical Principles for Medical Research Involving Human Subjects, the Council of Europe Convention on Human Rights and Biomedicine, the UNESCO Universal Declaration on the human genome and human rights and other appropriate national and institutional organisms' related standards were preserved.

Statistical analysis
The results of each questionnaire were compiled by Google Docs, an online questionnaire information storage program.The total responses to each question were compiled to perform the statistical analysis.Results were analyzed using IBM SPSS Statistics 19 and are presented as frequencies and percentages.

Attitudes to conscientious objection
In response to question 4 "do you believe that podiatrists should be entitled to object to any procedure for which they have a moral, cultural or religious disagreement?, a total of 276 (63,88%) respondents agreed with the statement, 156 (36,11%) students disagreed, while none was unsure.
Responses to this question are tabulated against the respondents' religion (table 1).Attitudes as to whether podiatrists have a right to conscientious objection varied between the reported religions.There is some similarity between the majority of the religious groups with 38-44% being opposed to any procedure with the exception of all Buddhist students who declared their disagreement, though Buddhist students are slightly representative in number.Values are number (%).The percentages are those within the religion.

Conscientious objection in podiatric specific practice
In question 6, students were asked if they would have an objection to performing 11 podiatric practices.The results are presented in table 2.
The total number of the objections raised across 11 procedures is 30,37% and they did not differ greatly between genders corresponding 56,15% to female students and 43,85% to male students.Nevertheless, with regard to conscientious objections to the 11 medical practices posed in the study, 54,40 % were for religious motives, 34,72 % were not for religious motives and 10,88 % were for both religious and not religious reasons.

Conscientious objection in podiatry
This survey revealed that more than a half of the students believed in the right of podiatrists to conscientiously object to any procedure(3).The same results are found in other medical studies that argue that qualified doctors acted on their conscience and refused to perform certain procedures.This shows the lack of strategies to deal with podiatrists' ethical dilemmas and the need to improve such procedures (8,9).Some of the podiatry students' objections can be due to those stated in the Spanish Constitution, in the human rights declaration and in the professional code of ethics(2, 10,11).This could explain the obtained results and the refusal to perform certain procedures, based on religious or moral beliefs.

Religious conscientious objection and addictions
This survey found a similar percentage of objections for religious and not religious reasons (3).The factors behind the non-religious objections were not specifically explored.Sometimes it is easier to understand an objection based on religious teachings, rather than on moral decisions, though both are of vital importance to improve the physical and emotional health of persons and healthcare providers (12).
Alcohol and recreational drugs additions are topics widely debated in conscientious objection (13).The survey revealed that one third of the students would not examine a person under the effects of alcohol and recreational drugs under the protection of their own moral integrity and claiming they could suffer some moral distress.These results could imply some future access restrictions to podiatry services for persons who suffer this type of addictions.The code of ethics recognizes the right to objection(2), hence an additional education orientated to social problems, biodiversity, solidarity, principles, values, care for others and self-care, should be implemented in general podiatry education and training in order to help the future specialists to resolve the ethical problems that arise in the healthcare activity (8).

Conclusion
This project sheds some light on how future podiatrist view some of their ethical rights and obligations.Using empirical evidence, it reveals that conscientious objection is an issue in the Spain podiatry student body today, especially among Christian Roman students, but also to the students of other religious.These data could help anticipate problems that may arise when these podiatry students qualify and practise podiatry in the community.

Table 1
Frequencies of responses, cross-tabulated by religion, to the question 'do you think that podiatrists should be entitled to object to any procedure for which they have a moral, cultural or religious disagreement?

Table 2
Students reporting an objection (religious, non-religious or both) to a total of 11 procedures.