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Opinion no. 385: The Limits of Conscientious Refusal in Reproductive Medicine

American College of Obstetricians and Gynecologists

American College of Obstetricians & Gynecologists

Abstract
Health care providers occasionally may find that providing indicated, even standard, care would present for them a personal moral problem-a conflict of conscience particularly in the field of reproductive medicine. Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled. All health care providers must provide accurate and unbiased information so that patients can make informed decisions. Where conscience implores physicians to deviate from standard practices, they must provide potential patients with accurate and prior notice of their personal moral commitments. Physicians and other health care providers have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. In resource-poor areas, access to safe and legal reproductive services should be maintained. Providers with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient’s physical or mental health, providers have an obligation to provide medically indicated and requested care.

ACOG. The Limits of Conscientious Refusal in Reproductive Medicine. ACOG Committee on Ethics. 2007;385):1-6.

Response to Commentators on “Conscientious Objection and Emergency Contraception”: Sex, Drugs and the Rocky Role of Levonorgestrel

Robert F Card

Extract
I thank the thoughtful commentators on my essay. Their contributions have deepened my grasp of the relevant issues. Unfortunately I cannot discuss each selection in turn, but will instead focus on several commentaries that purport to offer the most serious objections to my argument. . . I was inspired to write this article in order to examine some possible moral justifications for conscientious objection with respect to EC, given that objecting providers seemed to be under no obligation to even state their reasons for refusal. To the extent that this paper spurs further elaboration and evaluation of these reasons, I will consider it a success. (Responds to Farr Curlin, Carson Strong).

Card RF. Response to Commentators on “Conscientious Objection and Emergency Contraception”: Sex, Drugs and the Rocky Role of Levonorgestrel. Am J Bioeth. 2007;7(10):W4-W6.

(News) Doctors who give lethal injections should be punished, says Amnesty

Caroline White

British Medical Journal, BMJ — British Medical Journal

Extract
Doctors and other healthcare staff who take any part in executions by lethal injection should be punished by their professional bodies, says the human rights organisation, Amnesty International.

White C. Doctors who give lethal injections should be punished, says Amnesty. Br Med J. 2007 Oct 6;335(7622):690.

Abortion is more than a debate about conscientious objection

Jenny Talia

Extract
Too much effort is expended on debating the rights and wrongs about abortion and not enough is done to prevent it. What proportion of conscientious objectors makes a conscientious effort to ensure men and women use contraception? Conversely, is the pro-choice contingent too lax about initiating discussions on contraception to men and women opportunistically? Of course, there is responsibility for everyone along the chain. What I have a problem with are health professionals who not only deny the rights of women for abortion, but also refuse to offer contraception on religious and moral grounds and insist on abstention.

Talia J. Abortion is more than a debate about conscientious objection. BMJ Sex Repro Health. 2007;33(4):243.

Professionalism and the Medical Association

Jeff Blackmer

Extract
In many respects, medical professionalism is currently at a crossroads. The nature of the physician-patient relationship continues to evolve, as physicians struggle to redefine their role in an ever-changing society that is in the midst of a technological revolution. Threats to medical self-regulation and evolving physician scopes of practice have caused many practicing doctors to question whether the profession itself will ever be the same. . . . The objective of this paper has been to examine medical professionalism through the lens of the representative medical association rather than the individual clinician. Through providing both general and specific, concrete suggestions and examples of current and future potential activities which might be undertaken, it is hoped that it will add in a positive and constructive way to the preservation of what most doctors consider to be at the core of medicine: the role of the physician as healer and professional.

Blackmer J. Professionalism and the Medical Association. World Med Ass J. 2007;53(3):58-74.

Reconciling principles and prescriptions: Do pharmacist refusal clauses strike the appropriate balance between pharmacists’ and patients’ rights?

Sarah Tomkowiak

Extract
Conclusion: When a woman and her physician decide that a prescription for contraception is in her best health interests, legal, professional, and ethical obligations should prevent a pharmacist from being able to effectively override that determination. The right of a pharmacist to abide by her moral or religious principles when faced with a prescription that goes against those principles is an important right to protect. However, this right should never be allowed to infringe on a patient’s right to access birth control, an equally important right that has significant implications for the majority of American women’s reproductive health. Pharmacist refusal clauses acknowledge pharmacists’ right to refuse at the expense of women’s right to access contraceptives, inappropriately reconciling these rights. Griswold v. Connecticut may be forty years old, but the issues debated before the Supreme Court then have risen anew today, this time behind the pharmacy counter. Following in the footsteps of the Griswold Court, we must now reaffirm that women have the right to make their own family planning decisions, including the decision to use contraception. Legislatures, pharmacy boards, pharmacies, pharmacists, and patients must work together to put the needs of patients back where they belong—as the first priority of the pharmacy profession.

Tomkowiak S. Reconciling principles and prescriptions: Do pharmacist refusal clauses strike the appropriate balance between pharmacists’ and patients’ rights? U Illinois L Rev 2007(4) 1329-1360

Reasons and Healthcare Professionals’ Claims of Conscience (Conscientious Objection and Emergency Contraception)

Mark R Wicclair

Extract
Robert Card (2007) argues against even a limited conscience based right to refuse to dispense emergency contraception (EC) on the grounds that there are no “reasonable or justified” reasons to support such claims of conscience. This line of argument raises an important question: To what extent is it appropriate to assess reasons in relation to healthcare professionals’ claims of conscience?

Wicclair MR. Reasons and Healthcare Professionals’ Claims of Conscience (Conscientious Objection and Emergency Contraception). Am J Bioeth. 2007;7(6):21-22.

Conscience in America: the slippery slope of mixing morality with medicine

Georgia Chudoba

Extract

Extract
Conscience clauses in this country are becoming dangerously broad and over-inclusive. What was once a protection for physicians who objected to performing abortions is now a tool for religious activists to obstruct a patient’s right to contraceptives, sterilization, and any other medical procedure that they feel is “morally” wrong. The Legislature must place limits on these clauses to protect patients’ rights. At the onset of new medical research on stem cells and infertility treatments, it is crucial that Congress enact legislation that will protect patients’ rights to these treatments. There needs to be a balance between the doctor’s right of conscience and the patient’s right to treatment.

Chudoba G. Conscience in America: the slippery slope of mixing morality with medicine. Southwestern University Law Review. 2007;36(1):85-106.

Conscientious Objection the Morning After (Conscientious Objection and Emergency Contraception)

Carson Strong

Extract
In summary, Card supports his view with weak arguments, makes an erroneous assumption about the state of scientific inquiry, and misrepresents the argument of his opponents. When these various errors are brought to light, it becomes clear that Card has not successfully defended his extreme view. . . . Everyone accepts that conscientious refusal conflicts with the patient’s interests. The question is whether this particular type of failure to meet the patient’s interests can ever be ethically justifiable. Simply pointing out that there is a conflict does not constitute an argument. If a limited right to conscientious refusal is consistent with being a professional, then professional organizations that acknowledge such a right are not acting contrary to the purposes and roles of such organizations. What is needed to support de Melo-Martin’s position is an argument that conscientious refusals never, or at least hardly ever, override a patient’s interests, and de Melo-Martin does not provide this.

Strong C. Conscientious Objection the Morning After (Conscientious Objection and Emergency Contraception). Am J Bioethcs. 2007;7(6):32-34.

Caution: Conscience is the Limb on Which Medical Ethics Sits (Conscientious Objection and Emergency Contraception)

Farr A Curlin

Extract
Card (2007) does not merely claim that practitioners are obligated to provide EC; he argues that they are obligated to do so even if they have a conscientious objection. This last clause may seem harmless on the surface, but a closer look reveals that it effectively saws off the limb on which the first clause and all medical ethics sit. . . . A genuine conscientious objection, even if misinformed, is an expression of a commitment to acting morally, and . . . judgments of conscience need not be informed by explicitly religious ideas. Moreover, all ethical arguments are appeals to conscience. As such, acting conscientiously is the most fundamental of all moral obligations.

Curlin FA. Caution: Conscience is the Limb on Which Medical Ethics Sits (Conscientious Objection and Emergency Contraception). Am J Bioeth. 2007;7(6):30-31.