Extract As a whole, this collection of essays raises to the surface some of the key questions that underlie ongoing disputes about health-care practitioners refusing patients’ requests—namely, what is the conscience, and what is medicine? We hope that by foregrounding these questions and offering contrasting responses to them, this collection serves to bring greater clarity to ongoing disputes about what we might reasonably expect of physicians when patients request interventions that physicians do not believe they should provide.
Abstract Disputes about conscientious refusals reflect, at root, two rival accounts of what medicine is for and what physicians reasonably profess. On what we call the “provider of services model,” a practitioner of medicine is professionally obligated to provide interventions that patients request so long as the interventions are legal, feasible, and are consistent with well-being as the patient perceives it. On what we call the “Way of Medicine,” by contrast, a practitioner of medicine is professionally obligated to seek the patient’s health, objectively construed, and to refuse requests for interventions that contradict that profession. These two accounts coexist amicably so long as what patients want is for their practitioners to use their best judgment to pursue the patient’s health. But conscientious refusals expose the fact that the two accounts are ultimately irreconcilable. As such, the medical profession faces a choice: either suppress conscientious refusals, and so reify the provider of services model and demoralize medicine, or recover the Way of Medicine, and so allow physicians to refuse requests for any intervention that is not unequivocally required by the physician’s profession to preserve and restore the patient’s health.
Abstract Objective: Previous research has found that physicians are divided on whether they are obligated to provide a treatment to which they object and whether they should refer patients in such cases. The present study compares several possible scenarios in which a physician objects to a treatment that a patient requests, in order to better characterise physicians’ beliefs about what responses are appropriate.
Design: We surveyed a nationally representative sample of 1504 US primary care physicians using an experimentally manipulated vignette in which a patient requests a clinical intervention to which the patient’s physician objects. We used multivariate logistic regression models to determine how vignette and respondent characteristics affected respondent’s judgements. Results: Among eligible respondents, the response rate was 63% (896/1427). When faced with an objection to providing treatment, referring the patient was the action judged most appropriate (57% indicated it was appropriate), while few physicians thought it appropriate to provide treatment despite one’s objection (15%). The most religious physicians were more likely than the least religious physicians to support refusing to accommodate the patient’s request (38% vs 22%, OR=1.75; 95% CI 1.06 to 2.86). Conclusions: This study indicates that US physicians believe it is inappropriate to provide an intervention that violates one’s personal or professional standards. Referring seems to be physicians’ preferred way of responding to requests for interventions to which physicians object.
Mithya Lewis-Newby, Mark R Wicclair, Thaddeus Mason Pope, Cynda Rushton, Farr A Curlin, Douglas Diekema, Debbie Durrer, William Ehlenbach, Wanda Gibson-Scipio, Bradford Glavan, Rabbi Levi Langer, Constantine Manthous, Cecile Rose, Anthony Scardella, Hasan Shanawani, Mark D Siegel, Scott D. Halpern, Robert D Truog, Douglas B White
Abstract Rationale: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs.
Objectives: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting.
Methods: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law.
Main Results: The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield ” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting.
Conclusions: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians’ COs in the critical care setting.
Janelle N Sobecki, Farr A Curlin, Kenneth A Rasinski, Stacy Tessler Lindau
Abstract Introduction Sexuality is a key aspect of women’s physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well-positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women’s health more broadly, warrant up-to-date information regarding ob/gyns’ sexual history-taking routine.
Aims To determine obstetrician/gynecologists’ practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.
Methods A population-based sample of 1154 practicing U.S. obstetrician/gynecologists (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.
Main Outcome Measures Self-reported frequency measures of ob/gyns’ communication practices with patients including whether or not ob/gyns discuss patients’ sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients’ sexual practices. Multivariable analysis was used to correlate physicians’ personal and practice characteristics with these communication practices.
Results Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients’ sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients’ sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.
Conclusion The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients’ sexuality are not routinely discussed.
Grace S Chung, Ryan E Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin
Abstract Objective: The purpose of this study was to assess obstetrician- gynecologists’ regarding their beliefs about when pregnancy begins and to measure characteristics that are associated with believing that pregnancy begins at implantation rather than at conception.
Study Design: We mailed a questionnaire to a stratified, random sample of 1800 practicing obstetrician-gynecologists in the United States. The outcome of interest was obstetrician-gynecologists’ views of when pregnancy begins. Response options were (1) at conception, (2) at implantation of the embryo, and (3) not sure. Primary predictors were religious affiliation, the importance of religion, and a moral objection to abortion.
Results: The response rate was 66% (1154/1760 physicians). One-half of US obstetrician-gynecologists (57%) believe pregnancy begins at conception. Fewer (28%) believe it begins at implantation, and 16% are not sure. In multivariable analysis, the consideration that religion is the most important thing in one’s life (odds ratio, 0.5; 95% confidence interval, 0.20.9) and an objection to abortion (odds ratio, 0.4; 95% confidence interval, 0.20.9) were associated independently and inversely with believing that pregnancy begins at implantation.
Conclusion: Obstetrician-gynecologists’ beliefs about when pregnancy begins appear to be shaped significantly by whether they object to abortion and by the importance of religion in their lives.
Lisa H Harris, Alexandra Cooper, Kenneth A Rasinski, Farr A Curlin, Anne Drapkin Lyerly
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.
RE Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin
Abstract Background Given recent legislative efforts to require parental notification for the provision of reproductive health care to minors, we sought to assess how ob/gyns respond to requests for confidential contraceptive services.
Study Design Mailed survey of 1800 U.S. Obstetrician-Gynecologists, utilizing a vignette where a 17-year-old college freshman requests birth control pills and does not want her parents to know. Criterion variables were the likelihood of: encouraging her to abstain from sexual activity until she is older; persuading her to involve her parents in this decision; and prescribing contraceptives without notifying her parents. Covariates included physicians’ religious, demographic, and clinical characteristics.
Results Response rate 66%. Most (94%) would provide contraceptives without notifying her parents. Half (47%) would encourage her to involve a parent, and half (54%) would advise abstinence until she is older. Physicians who frequently attend religious services were more likely to encourage her to involve her parents (OR 1.9), and to abstain from sex until she is older (OR 4.4), but equally likely to provide the contraceptives.
Conclusions Most obstetrician-gynecologists will provide adolescents with contraceptives without notifying their parents.
RE Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin
Abstract Objective To examine obstetrician–gynecologists’ beliefs about safe-sex and abstinence counseling.
Methods Between October 2008 and January 2009, a survey was mailed to a national randomized sample of 1800 practicing US obstetrician–gynecologists. Study variables were agreement with 2 statements. (1) “If physicians counsel patients about safe-sex practices, the patients will be less likely to engage in risky sexual behaviors”. (2) “If physicians counsel patients about abstinence, the patients will be much less likely to engage in sexual activity”. Covariates included demographic, clinical, and religious characteristics of the physician.
Results The response rate was 66% (1154/1760 eligible physicians). Most respondents somewhat (62%) or strongly (25%) agreed that counseling patients about safe-sex practices makes patients less likely to engage in risky sexual behaviors. Fewer agreed strongly (3%) or somewhat (28%) that counseling patients about abstinence makes patients less likely to engage in sexual activity. The belief that safe-sex counseling reduces risky behaviors was less common among males (odds ratio [OR] 0.6) and more common among immigrants (OR 2.0). Religious physicians were more likely to believe that abstinence counseling reduces sexual activity (OR 2.2–5.3).
Conclusions Most obstetrician–gynecologists believed that counseling about safe sex is effective, and a significant minority endorsed abstinence counseling.
Kenneth A Rasinski, John D Yoon, Youssef G Kalad, Farr A Curlin
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.