Physicians, “Conscience,” and the Denial of Options

“Doctors and other health care providers should not be forced to choose between good professional standing and violating their conscience,” said Health and Human Services Secretary Mike Leavitt, announcing the Final Regulations to Protect Health Care Providers from Discrimination last month. “This rule protects the right of medical providers to care for their patients in accord with their conscience.”

Part of the last minute flurry of regulations being passed by the Bush administration before President-elect Obama takes office, the rule is intended to protect health care providers who oppose abortion and other medical procedures on religious and moral grounds. Once the rule goes into effect, institutions that receive federal funds will be prohibited from discriminating against doctors, nurses, and other medical personnel who refrain from abortion and other medical procedures on such grounds. However, the rule includes no stipulation that other medical providers be available to offer these services, effectively limiting some Americans’ access to health care services in the process.

The American Medical Association, American Nurses Association, American Hospital Association, Planned Parenthood, and other major health care organizations oppose the new rule because of the restrictions it places on health care access, and the fact that it overlaps with existing civil rights legislation. The Catholic Health Association, United States Conference of Catholic Bishops, and Christian Medical and Dental Association support the rule and the protection it offers to “medical personnel from being coerced to violate their consciences in federally-funded programs,” according to a USCCB spokesperson.

Debates about conscience-based objections in health care are not new, but part of ongoing negotiations focused most prominently in the last few years on whether pharmacists are obliged to dispense birth control when it conflicts with their personal beliefs. Farr Curlin, a physician at the University of Chicago who conducts research about conscientious objection in medicine, says that most people believe simultaneously that health care providers should not have to engage in medical practices they object to and that patients should have access to legal treatments even when their physicians have such objections. Historically, medical personnel have not been required to participate in procedures they oppose for moral reasons; in fact, several states have passed measures in recent years reflecting such norms.

In February 2007, Curlin and colleagues published one of the first empirical studies of religion, conscience, and controversial clinical practices in the New England Journal of Medicine. Based on a survey completed by 1144 randomly-selected physicians who belong to the American Medical Association, Curlin found that most physicians (63%) believe it is appropriate for physicians to explain to patients their moral objections to practices such as terminal sedation (“administering sedation that leads to unconsciousness in dying patients”), abortion for failed contraception, and prescribing birth control to adolescents without parental consent. The vast majority of physicians (86%) also felt, however, that they are still obliged to present patients with all of the options when they object to a medical procedure, and to refer the patient to other physicians who do not have the same objections (71%).

The religious backgrounds of physicians—measured by religious service attendance, religious affiliation, and measures of intrinsic religiosity—influenced how physicians answered these questions. Physicians who were male, religious, and had personal objections to clinical practices were less likely to believe that doctors must present patients with all the options and to provide referrals when they had objections.

When generalized to the US population, Curlin argues that these findings indicate that 14% of patients—more than 40 million Americans—may have physicians who do not believe they need to present patients with all of the options when they personally object to a medical treatment. Nearly 29% of patients—close to 100 million Americans—may be cared for by physicians who do not believe they must refer patients to other providers in such situations.

These numbers should give us pause. Combined with the new medical conscience rule they make it even more important that Americans are proactive about their health care. Patients and family members should select physicians carefully and consider questioning them about medical options and alternatives, especially when a practice is potentially controversial. We might consider talking with our physicians when we first meet them about their positions on issues that are important to us, to be sure we will get the care we want should it become necessary.

By not mandating that medical personnel be available to provide services when their colleagues object on religious or ethical grounds, the medical conscience rule privileges physicians’ rights of conscience over patients’ rights to treatment. Few Americans want physicians to violate their conscience. Even fewer want to be denied health care services as a result.

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