Farr A Curlin Archives - Page 2 of 4 - Protection of Conscience Project Library

Conscientious refusals to refer: Findings from a national physician survey

Michael P Combs, Ryan M Antiel, Jon C Tilburt, Paul S Mueller, Farr A Curlin

Abstract
Background: Regarding controversial medical services, many have argued that if physicians cannot in good conscience provide a legal medical intervention for which a patient is a candidate, they should refer the requesting patient to an accommodating provider. This study examines what US physicians think a doctor is obligated to do when the doctor thinks it would be immoral to provide a referral.

Method: The authors conducted a cross-sectional survey of a random sample of 2000 US physicians from all specialties. The primary criterion variable was agreement that physicians have a professional obligation to refer patients for all legal medical services for which the patients are candidates, even if the physician believes that such a referral is immoral.

Results: Of 1895 eligible physicians, 1032 (55%) responded. 57% of physicians agreed that doctors must refer patients regardless of whether or not the doctor believes the referral itself is immoral. Holding this opinion was independently associated with being more theologically pluralistic, describing oneself as sociopolitically liberal, and indicating that respect for patient autonomy is the most important bioethical principle in one’s practice (multivariable ORs, 1.6-2.4).

Conclusions: Physicians are divided about a professional obligation to refer when the physician believes that referral itself is immoral. These data suggest there is no uncontroversial way to resolve conflicts posed when patients request interventions that their physicians cannot in good conscience provide..

Combs MP, Antiel RM, Tilburt JC, Mueller PS, Curlin FA. Conscientious refusals to refer: Findings from a national physician survey. J Med Ethics. 2011;37(7):397-401. Available from:

Obstetrician-gynecologists’ views on contraception and natural family planning: a national survey

RE Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin

American Journal of Obstetrics & Gynecology

Abstract
Objective
To characterize beliefs about contraception among obstetrician-gynecologists (Ob/Gyns).

Study design
National mailed survey of 1800 U.S. Ob/Gyns. Criterion variables were whether physicians have a moral or ethical objection to – and whether they would offer – six common contraceptive methods. Covariates included physician demographic and religious characteristics.

Results
1154 of 1760 eligible Ob/Gyns responded (66%). Some Ob/Gyns object to intrauterine devices (4.4% object, 3.6% would not offer), progesterone implants and/or injections (1.7% object, 2.1% would not offer), tubal ligations (1.5% object, 1.5% would not offer), oral contraceptive pills (1.3% object, 1.1% would not offer), condoms (1.3% object, 1.8% would not offer), and the diaphragm or cervical cap with spermicide (1.3% object, 3.3% would not offer). Religious physicians were more likely to object (OR 7.4) and to refuse to provide a contraceptive (OR 1.9).

Conclusion
Controversies about contraception are ongoing, but among Ob/Gyns objections and refusals to provide contraceptives are infrequent.

Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Obstetrician-gynecologists’ views on contraception and natural family planning: a national survey. Am J Obstet Gynecol. 2011;204(2):124e1-124e7.

Factors influencing physicians’ advice about female sterilization in USA: a national survey

RE Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin

Abstract
Background
Tubal ligation can be a controversial method of birth control, depending on the patient’s circumstances and the physician’s beliefs.

Methods
In a national survey of 1800 US obstetrician-gynecologist (Ob/Gyn) physicians, we examined how patients’ and physicians’ characteristics influence Ob/Gyns’ advice about, and provision of, tubal ligation. Physicians were presented with a vignette in which a patient requests tubal ligation. The patient’s age, gravida/parity and her husband’s agreement/disagreement were varied in a factorial experiment. Criterion variables were whether physicians would discourage tubal ligation, and whether physicians would provide the surgery.

Results
The response rate was 66% (1154/1760). Most Ob/Gyns (98%) would help the patient to obtain tubal ligation, although 9–70% would attempt to dissuade her, depending on her characteristics. Forty-five percent of physicians would discourage a G2P1 (gravida/parity) woman, while 29% would discourage a G4P3 woman. Most physicians (59%) would discourage a 26-year-old whose husband disagreed, while 32% would discourage a 26-year-old whose husband agreed. For a 36-year-old patient, 47% would discourage her if her husband disagreed, while only 10% would discourage her if her husband agreed. Physicians’ sex had no significant effect on advice about tubal ligation.

Conclusions
Regarding patients who seek surgical sterilization, physicians’ advice varies based on patient age, parity and spousal agreement but almost all Ob/Gyns are willing to provide or help patients obtain surgical sterilization if asked. An important limitation of the study is that a brief vignette, while useful for statistical analysis, is a rough approximation of an actual clinical encounter.

Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Factors influencing physicians’ advice about female sterilization in USA: a national survey. Hum Reprod. 2011;26(1):106-111.

Obstetrician-gynecologist physicians’ beliefs about emergency contraception: a national survey

Ryan E Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin

Abstract
Background: Although emergency contraception (EC) is available without a prescription, women still rely on doctors’ advice about its safety and effectiveness. Yet little is known about doctors’ beliefs and practices in this area.

Study design: We surveyed 1800 US obstetrician-gynecologists. Criterion variables were doctors’ beliefs about EC’s effects on pregnancy rates, and patients’ sexual practices. We also asked which women are offered EC. Predictors were demographic, clinical and religious characteristics.

Results: Response rate was 66% (1154/1760). Most (89%) believe EC access lowers unintended pregnancy rates. Some believe women use other contraceptives less (27%), initiate sex at younger ages (12%) and have more sexual partners (15%). Half of physicians offer EC to all women (51%), while others offer it never (6%) or only after sexual assault (6%). Physicians critical of EC, males and religious physicians were more likely to offer it never or only after sexual assault (odds ratios 2.1-12).

Conclusion: Gender, religion and divergent beliefs about EC’s effects shape physicians’ beliefs and practices.

Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Obstetrician-gynecologist physicians’ beliefs about emergency contraception: a national survey. Contraception. 2010;82(324-330.

Religious Hospitals and Primary Care Physicians: Conflicts over Policies for Patient Care

Debra B Stulberg, Ryan E Lawrence, Jason Shattuck, Farr A Curlin

Abstract
BACKGROUND
Religiously affiliated hospitals provide nearly 20% of US beds, and many prohibit certain end-of-life and reproductive health treatments. Little is known about physician experiences in religious institutions.
OBJECTIVE
Assess primary care physicians’ experiences and beliefs regarding conflict with religious hospital policies for patient care.
DESIGN
Cross-sectional survey.
PARTICIPANTS
General internists, family physicians, and general practitioners from the AMA Masterfile.
MAIN MEASURES
In a questionnaire mailed in 2007, we asked physicians whether they had worked in a religiously affiliated hospital or practice, whether they had experienced conflict with the institution over religiously based patient care policies and how they believed physicians should respond to such conflicts. We used chi-square and multivariate logistic regression to examine associations between physicians’ demographic and religious characteristics and their responses.
KEY RESULTS
Of 879 eligible physicians, 446 (51%) responded. In analyses adjusting for survey design, 43% had worked in a religiously affiliated institution. Among these, 19% had experienced conflict over religiously based policies. Most physicians (86%) believed when clinical judgment conflicts with religious hospital policy, physicians should refer patients to another institution. Compared with physicians ages 26–29 years, older physicians were less likely to have experienced conflict with religiously based policies [odds ratio (95% confidence interval) compared with 30–34 years: 0.02 (0.00–0.11); 35–46 years: 0.07 (0.01–0.72); 47–60 years: 0.02 (0.00–0.10)]. Compared with those who never attend religious services, those who do attend were less likely to have experienced conflict [attend once a month or less: odds ratio 0.06 (0.01–0.29); attend twice a month or more: 0.22 (0.05–0.98)]. Respondents with no religious affiliation were more likely than others to believe doctors should disregard religiously based policies that conflict with clinical judgment (13% vs. 3%; p = 0.005).
Conclusions
Hospitals and policy-makers may need to balance the competing claims of physician autonomy and religiously based institutional policies.

Stulberg DB, Lawrence RE, Shattuck J, Curlin FA. Religious Hospitals and Primary Care Physicians: Conflicts over Policies for Patient Care. J Gen Intern Med. 2010;25(7):725-730. Available from:

Physicians’ beliefs about conscience in medicine: a national survey

Ryan E Lawrence, Farr A Curlin

Abstract
PURPOSE: To explore physicians’ beliefs about whether physicians sometimes have a professional obligation to provide medical services even if doing so goes against their conscience, and to examine associations between physicians’ opinions and their religious and ethical commitments.

METHOD: A survey was mailed in 2007 to a stratified random sample of 1,000 U.S. primary care physicians, selected from the American Medical Association Physician Masterfile. . . .

RESULTS: The response rate was 51% (446/879 delivered questionnaires). Forty-two percent and 22% believed they are never and sometimes, respectively, obligated to do what they personally believe is wrong, and 36% agreed with both statements. Physicians who are more religious are more likely to believe that physicians are never obligated to do what they believe is wrong (58% and 31% of those with high and low intrinsic religiosity, respectively; multivariate odds ratio, 2.9; 95% CI, 1.2-7.2). Those with moral objections to any of three controversial practices were more likely to hold that physicians should never do what they believe is wrong.

CONCLUSION: A substantial minority of physicians do not believe there is ever a professional obligation to do something they personally believe is wrong.

Lawrence RE, Curlin FA. Physicians’ beliefs about conscience in medicine: a national survey.. Acad Med. 2009;84(9):1276-1282.

Autonomy, religion and clinical decisions: findings from a national physician survey

RE Lawrence, Farr A Curlin

Abstract
Background: Patient autonomy has been promoted as the most important principle to guide difficult clinical decisions. To examine whether practising physicians indeed value patient autonomy above other considerations, physicians were asked to weight patient autonomy against three other criteria that often influence doctors’ decisions. Associations between physicians’ religious characteristics and their weighting of the criteria were also examined.

Methods: Mailed survey in 2007 of a stratified random sample of 1000 US primary care physicians, selected from the American Medical Association masterfile. Physicians were asked how much weight should be given to the following: (1) the patient’s expressed wishes and values, (2) the physician’s own judgment about what is in the patient’s best interest, (3) standards and recommendations from professional medical bodies and (4) moral guidelines from religious traditions.

Results: Response rate 51% (446/879). Half of physicians (55%) gave the patient’s expressed wishes and values “the highest possible weight”. In comparative analysis, 40% gave patient wishes more weight than the other three factors, and 13% ranked patient wishes behind some other factor. Religious doctors tended to give less weight to the patient’s expressed wishes. For example, 47% of doctors with high intrinsic religious motivation gave patient wishes the “highest possible weight”, versus 67% of those with low (OR 0.5; 95% CI 0.3 to 0.8).

Conclusions: Doctors believe patient wishes and values are important, but other considerations are often equally or more important. This suggests that patient autonomy does not guide physicians’ decisions as much as is often recommended in the ethics literature.

Lawrence RE, Curlin FA. Autonomy, religion and clinical decisions: findings from a national physician survey. J Med Ethics. 2009;35, 214-218.

Conscience and clinical practice: Medical ethics in the face of moral controversy

Farr A Curlin

Abstract
Physicians sometimes refuse to provide legally permitted medical services on the grounds that they cannot do so in good conscience. Such conscientious refusals are at least as old as the Hippocratic movement. Yet new events, such as the refusal by health care professionals to prescribe or dispense post-coital (‘‘emergency’’) contraception, have kindled new debates about what physicians are obligated to do when patients request legal medical interventions to which their physicians have moral objections. In a recent national survey, we found that a large majority of physicians believe they are obligated in such circumstances to present all possible options to the patient, including information about obtaining the requested intervention, and to refer the patient to a clinician who does not object to the requested intervention. Yet a substantial minority of physicians—particularly those who are more religious and/or who themselves object to common controversial practices—disagree with these majority opinions.

Curlin FA. Conscience and clinical practice: Medical ethics in the face of moral controversy. Theor Med Bioeth. 2008;29(3):129-133.

To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support

Farr A Curlin, Chinyere Nwodim, Jennifer L Vance, Marshall H Chin, John D Lantos

American Journal of Hospice and Palliative Care

Abstract
This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians’ religious characteristics, ethnicity, and experience caring for dying patients.

Curlin FA, Nwodim C, Vance JL, Chin MH, Lantos JD. To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support. American J Hospice & Pall Care. 2008;25(12):112-120.

Professional Responsibility and Individual Conscience: Protecting the Informed Consent Process from Impermissible Bias

Frank A Chervenak, Laurence B McCullough

Extract
The ethics of referral for abortion is autonomy based with a beneficence-based component, the clinician’s obligation to protect the woman’s health and life, similar to referral for cosmetic procedures. At a minimum, indirect referral— providing referral information but not ensuring that referral occurs—should be the clinical ethical standard of care. Direct referral for abortion is a matter of individual clinician discretion, not the clinical ethical standard of care. Conscience based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral for termination of pregnancy do not.

Chervenak FA, McCullough LB. Professional Responsibility and Individual Conscience: Protecting the Informed Consent Process from Impermissible Bias. J Clin Ethics. 2008 Spring;19(1):24-25.