Abstract Catholic physicians practice in a world that condones the use of contraception. In the effort to be morally consistent, questions arise regarding the extent to which one’s participation in the provision of contraceptives constitutes immoral cooperation in evil. Particular challenges face the resident physician, who practices under another physician and within the constraints of local and specialty-wide training requirements. We examine the nature of the moral act of “referring” for contraception and argue that, in limited cases,there is a moral distinction between a referral and an intra-residency patient transfer, and the latter may be morally licit according to the principle of material cooperation
Abstract Bernard Dickens seeks to undermine the legal and ethical protections accorded to health care workers and hospitals conscientiously objecting to abortion. First, he appeals to the rationale of antidiscrimination laws as a basis for arguing against conscientious objection. Second, he argues that conscientious objection undermines the rights of patients and their autonomy. Third, he holds that conscientiously objecting doctors have a duty to refer patients for abortion. Fourth, he believes that Kant’s principle of respect for humanity as an end in itself is violated by conscientious objection to abortion. Fifth, Dickens quotes remarks by Pope John Paul II as support for the idea that physicians should not conscientiously object to abortion. Finally, he posits that institutions, such as Catholic hospitals, have a responsibility to provide abortions. I argue that all of the arguments offered by Dickens against conscientious objection are unsound.
Lisa H Harris, Alexandra Cooper, Kenneth A Rasinski, Farr A Curlin, Anne Drapkin Lyerly
Obstetrics & Gynecology
Abstract Objective: To describe obstetrician-gynecologists’ (ob-gyns’) views and willingness to help women seeking abortion in a variety of clinical scenarios.
Methods: We conducted a mailed survey of 1,800 U.S. ob-gyns. We presented seven scenarios in which patients sought abortions. For each, respondents indicated if they morally objected to abortion and if they would help patients obtain an abortion. We analyzed predictors of objection and assistance.
Results: The response rate was 66%. Objection to abortion ranged from 16% (cardiopulmonary disease) to 82% (sex selection); willingness to assist ranged from 64% (sex selection) to 93% (cardiopulmonary disease). Excluding sex selection, objection was less likely among ob-gyns who were female (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.4-0.8), urban (OR 0.3, 95% CI 0.1-0.7), or Jewish (OR 0.3, 95% CI 0.1-0.7) compared with male, rural, or religiously unaffiliated ob-gyns. Objection was more likely among ob-gyns from the South (OR 1.9, 95% CI 1.2-3.0) or Midwest (OR 1.9, 95% CI 1.2-3.1), and among Catholic, Evangelical Protestant, or Muslim ob-gyns, or those for whom religion was most important, compared with reference. Among ob-gyns who objected to abortion in a given case, approximately two-thirds would help patients obtain an abortion. Excluding sex selection, assistance despite objection was more likely among female (OR 1.8, 95% CI 1.1-2.9) and United States-born ob-gyns (OR 2.2, 95% CI 1.1-4.7) and less likely among southern ob-gyns (OR 0.3, 95% CI 0.2-0.6) or those for whom religion was most important (OR 0.3, 95% CI 0.1-0.7).
Conclusion: Most ob-gyns help patients obtain an abortion even when they morally object to abortion in that case. Willingness to assist varies by clinical context and physician characteristics.
Extract Beware of arguments that appear to accept that CO is just about our ‘personal values’; it isn’t. Beware of relying on our fallen consciences rather than on God’s Word. Beware of resorting to the safety of guidelines and laws which may be changed. By God’s grace, we have the right to CO made explicit in our professional guidance, given concrete examples in the law, supported by a European assembly. We can argue from history or personal example in favour of it. But in the end, we need to be prepared to stand for Christ, and the experience of those before us suggests that this will be costly.
Kenneth A Rasinski, John D Yoon, Youssef G Kalad, Farr A Curlin
Journal of Medical Ethics
Abstract Background and objectives: Conscientious refusal of abortion has been discussed widely by medical ethicists but little information on practitioners’ opinions exists. The American College of Obstetricians and Gynecologists (ACOG) issued recommendations about conscientious refusal. We used a vignette experiment to examine obstetrician-gynecologists’ (OB/GYN) support for the recommendations.
Design: A national survey of OB/GYN physicians contained a vignette experiment in which an OB/GYN doctor refused a requested elective abortion. The vignette varied two issues recently addressed by the ACOG ethics committee–whether the doctor referred and whether the doctor disclosed their objection to the abortion.
Participants and setting: 1800 OB/GYN randomly selected physicians were asked to complete a mail survey containing the vignette. The response rate was 66% (n=1154) after excluding 40 ineligible cases.
Measurement: Physicians indicated their approval for the vignette doctor’s decision.
Main results: Overall, 43% of OB/GYN physicians responded that the conscientious refusal exercised by the vignette physician was appropriate. 70% rated the vignette doctor as acting appropriately when a referral was made. This dropped to 51% when the doctor disclosed objections to the patient, and to 12% when the doctor disclosed objections and refused to make a referral. Consistent with previous research, males were more likely to support disclosure and refusal to refer. Highly religious physicians supported non-referral but not disclosure.
Conclusion: OB/GYN physicians are less likely to support conscientious refusal of abortion if physicians disclose their objections to patients. This is at odds with ACOG recommendations and with some models of the doctor-patient relationship.
Michael P Combs, Ryan M Antiel, Jon C Tilburt, Paul S Mueller, Farr A Curlin
Journal of Medical Ethics
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..
Extract Conclusion . . . Currently, ambiguities in the Maryland statute allow too much flexibility for providers in emergency rooms to refuse to provide or even inform patients about emergency contraception. This kind of state sanctioned refusal serves as the kind of government obstacle the Supreme Court has forbidden in upholding a woman’s right to bodily privacy. The Maryland legislature should act to eliminate the ambiguities in Maryland’s conscience legislation and explicitly protect a woman’s right to access emergency contraception in Maryland emergency rooms. In order to do so, the Maryland legislature should adopt the medical community’s definition for abortion that excludes emergency contraception. The new Maryland conscience statute should also provide explicit protections to patients receiving emergency room care. Physicians should be required to inform patients of emergency contraception if treatment in each particular case is medically indicated. Finally, physicians should be required to treat patients that request access to emergency contraception or to refer them to another provider who is willing to administer treatment within the effective time period of emergency contraception. . .
Extract What duties accompany conscientious objection? To sum up what follows: The obligations to the patient remain unchanged, but for the denial of the contested request.
Specifically, what do these obligations entail? First, following from the very meaning of professing—and to develop a point previously mooted—full disclosure imposes the obligation to promulgate to the relevant parties one’s conscientious objection. This includes one’s prospective and current patients, colleagues, employers, and relevant institutions, for example hospitals and insurance companies. . . .
Second, conscientious objector status obliges the relevant professional to explain her reasons for her objection to those patients who request further information. . . . the patient is due the offer of an explanation. This does not, however, amount to the professional’s having a right to pontificate concerning the relevant matter. Rather, the interested patient ought to receive some answer to the question as to why the professional objects. Certainly, not all patients will be interested to know why. Those who are not interested ought not to be treated as captive audiences; those who do want to know ought to receive a considerate and considered answer. . .
Third, conscientious objector status bears exclusively on the patient’s contested request; it does not relate to the other care the physician, nurse, or pharmacist provides for the patient. If a relationship exists with the patient . . . the physician, nurse, or pharmacist must provide care to which she does not object. . .
Fourth, conscientious objector status requires the continued maintenance of confidentiality, particularly with respect to the fact that the professional objects to something the patient requests. . . .the professional must strenuously and scrupulously protect the patient’s privacy specifically concerning the patient’s request and the practitioner’s conscientious objection.
Finally, as earlier noted, while conscientious objection does not require referral to a third party who will abide by the patient’s request, it does require transfer of relevant documents, returning a prescription, and, more generally, acts which, while they may result in the act to which one objects, do not require one to aim at that act.
Extract The administration of former President George W. Bush and the subsequent revival of the abortion disputes in the United States have put the ethical challenges of conscientious objection in the spotlight in many international journals on bioethics in the last decade. . . . In the last few years some clear administrative guidelines have been drawn up, considering the institutional realities of developed countries, most of them with private healthcare systems. These include rules that the objection or refusal is an individual right and not an institutional right and healthcare providers have a duty to refer a woman to a similar health care service provider.
I would suggest that this is not the reality for many developing countries.
American Academy of Pediatrics Committee on Bioethics
Pediatrics
Abstract Health care professionals may have moral objections to particular medical interventions. They may refuse to provide or cooperate in the provision of these interventions. Such objections are referred to as conscientious objections. Although it may be difficult to characterize or validate claims of conscience, respecting the individual physician’s moral integrity is important. Conflicts arise when claims of conscience impede a patient’s access to medical information or care. A physician’s conscientious objection to certain interventions or treatments may be constrained in some situations. Physicians have a duty to disclose to prospective patients treatments they refuse to perform. As part of informed consent, physicians also have a duty to inform their patients of all relevant and legally available treatment options, including options to which they object. They have a moral obligation to refer patients to other health care professionals who are willing to provide those services when failing to do so would cause harm to the patient, and they have a duty to treat patients in emergencies when referral would significantly increase the probability of mortality or serious morbidity. Conversely, the health care system should make reasonable accommodations for physicians with conscientious objections.
