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Conscientious objection in Spanish podiatrists students: a questionnaire survey/Objecion de conciencia en estudiantes espanoles de podologia: estudio mediante cuestionario/Objecao de consciencia em estudantes de podologia na espanha: um questionario de sondagem.


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^). 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.



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.


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 Coruna, 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.



A large sample size of students completed the questionnaire, of a total of 850 podiatry students invited to take part, 432 responded, giving a response rate of 50,82%. Of those who responded, 176 (40,74%) indicated their gender to be male and 256 (59,25%) female, with no missing responses. Hundred seventy nine (41,43 %) declared they had not religion, 9 (2,08%) were agnostic, 1 (0,23%) was Hindu, 5 (1,15%) were Buddhist, 3 (0,69%) were Muslim, 233 (55, 21%) were Roman Catholic, 1 (0,23%) was Protestant, and 1 (0,23%) was Jewish.

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.

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).


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.

Funding: None.


(1.) Losa Iglesias ME, Becerro de Bengoa R, Paloma Salvadores P Moral distress related to ethical dilemmas among Spanish podiatrists. J Med Ethics 2010; 36(5): 310-314.

(2.) Codigo Deontologico de la Podologia. Madrid: Consejo General de Colegios Oficiales de Podologos; 2004: 2.

(3.) Strickland SL. Conscientious objection in medical students: a questionnaire survey. J Med Ethics 2012; 38: 22-25.

(4.) Nordstrand SJ, Nordstrand MA, Nortvedt P, et al. Medical students' attitudes towards conscientious objection: a survey. J Med Ethics 2014; 40: 609-612.

(5.) Card RF. Is there no alternative? Conscientious objection by medical students. J Med Ethics 2012; 38(10): 602-604.

(6.) Combs MP, Antiel RM, Tilburt JC, et al. Conscientious refusals to refer: findings from a national physician survey. J Med Ethics 2011; 37(7): 397-401.

(7.) Google Docs. Available from (acceses 20 nov 2014).

(8.) Losa Iglesias ME, Becerro de Bengoa R, Salvadores P, et al. Comparative analysis of moral distress and values of the work organization between American and Spanish Podiatric Physicians. J Am Podiatr Med Assoc 2012; 102(1): 57-63.

(9.) Losa Iglesias ME, Becerro de Bengoa R. Musculoskeletal Pain, Job Satisfaction, Depression, and Anxiety Among Spanish Podiatric Physicians. J Am Podiatr Med Assoc 2014; 104 (2): 191-197.

(10.) CE. Constitucion Espanola. Available from jsp?art=14&tipo=2 (accessed 13 Oct 2014).

(11.) Ministerio de Justicia. Tribunal Europeo de Derechos Humanos. Available from Portal/es/areas-tematicas/area-internacional/tribunal-europeo-derechos (accessed 13 Oct 2014).

(12.) Losa Iglesias ME, Becerro de Bengoa Vallejo R, Salvadores Fuentes P Reflections on the burnout syndrome and its impact on health care providers. Ann Afr Med 2010; 9(4):197-198.

(13.) Geppert CMA, Bogenschutz MP. Ethics in substance use disorder treatment. Psychiatr Clin N Am 2009; 32(2): 283- 297.

Received: 22 December 2014

Accepted: December 29, 2014

Daniel Lopez Lopez [1], Rosa Mary de la Campa Portela [1], Marta Elena Losa Iglesias [2], Jose Ramos Galvan [3], Pedro Vicente Munuera Martinez [3], Matilde Garcia Sanchez [1], Ricardo Becerro de Bengoa Vallejo [4]

[1] Unidad de Investigacion Salud y Podologia, Departamento de Ciencias de la Salud, Facultad de Enfermeria y Podologia, Universidade da Coruna, Espana Correspondencia:

[2] Facultad Ciencias de la Salud, Universidad Rey Juan Carlos, Espana

[3] Departamento de Podologia, Facultad de Enfermeria, Fisioterapia y Podologia, Universidad de Sevilla, Espana

[4] Fisioterapia y Podologia, Facultad de Medicina, Escuela Universitaria de Enfermeria, Universidad Complutense de Madrid, Espana
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

Religion          Yes             No            Total

Agnostic          5 (55,56 %)     4 (44,44%)    9
Buddhist          0 (0 %)         5 (100%)      5
Jewish            1 (100%)        (0%)          1
Hindu             1 (100%)        (0%)          1
Muslim            2 (100%)        0 (0%)        3
None or atheist   110 (61,45 %)   69 (38,54%)   179
Protestant        1 (100%)        (0%)          1
Roman Catholic    155 (66,52 %)   78 (33,48%)   233

Values are number (%). The percentages are those within the religion.

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

Procedure          Students reporting       Students who would not
                   objection to procedure   perform procedure (%)

Care for a         9 (2,08%)                423 (97,92%)
person who lacks

Examining or       131 (30,32%)             301 (69,67%)
treating a
intoxicated with

Examining or       131 (30,32%)             301 (69,67%)
treating a
intoxicated with

Examining or       17 (3,94%)               415 (96,06%)
treating a
patient who is
in favor of

Examining or       3 (0,69%)                429 (99,31%)
treating a
patient who has

I have             131 (30,32%)             301 (69,67%)
objection on
moral, cultural
and religious

Intimately         5 (1,16%)                427 (98,84%)
examining a
person of the
opposite sex

Learning about     13 (3,1%)                419 (96,99%)
the clinical
impact of
alcohol at
podiatry school

Learning about     11 (2,55%)               421 (97,45%)
the moral
abortion at
podiatry school

Learning about     17 (3,94%)               415 (96,06%)
the moral
euthanasia at
podiatry school

Prescription of    150 (34,72%)             282 (65,28%)
established by
the patient
without any
agreement with
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Article Details
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Author:Lopez, Daniel Lopez; de la Campa Portela, Rosa Mary; Iglesias, Marta Elena Losa; Galvan, Jose Ramos;
Publication:Acta Bioethica
Article Type:Ensayo
Date:Nov 1, 2016
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