On Conscience Clauses and Provider Privilege

7 Jul

Robin Marty at RHRealityCheck reports on a bill in Idaho that would extend protections to medical personnel who refuse to provide certain kinds of care based on their personal beliefs (read: contraception, abortion, and end of life care). As end of life care falls out of the purview of this blog, I’ll stick with reproductive health.

Conscience clauses have a long and ugly history. The basic idea is that doctors, nurses and pharmacists who are against abortion or contraception should have the right to refuse to provide such services, as well as the right to refuse to refer for such services. Because these providers are required by their licensing and professional agreements to provide all legal professional services falling within their scope of practice, they risk lawsuits or disciplinary action for refusing to provide them. To protect these pious individuals, states (and even the federal government) have enacted conscience clauses, which allow them to refuse to provide care with impunity. According to the Guttmacher Institute, 46 states allow some clinicians to refuse to provide abortion services, 44 of which allow health care institutions to refuse to provide abortion services. 14 states allow providers to refuse to provide contraception, and 18 states allow providers to refuse to provide sterilization services.

Why is this a problem? Providers shouldn’t be forced to do anything that’s against their personal or religious beliefs, right?

Wrong. These clauses are an abuse of power. The doctor- (or nurse- or PA-) patient relationship is inherently unequal. The clinician has expertise that the patient does not. Refusing to provide care that is legal, necessary, or requested is an abuse of the trust that relationship engenders. It implies judgment of a woman’s decisions and represents the worst kind of paternalism. Women seeking emergency contraception and abortion services at times seem to me the most disempowered of all the women I care for (I would argue this is because we fail them in so many ways as health care providers). To refuse to provide them with the best care is unethical.

These clauses are harmful to patients. The American College of Obstetrics and Gynecology reports on several cases where women have experienced harm due to doctors, nurses, and pharmacists exercising their right to refuse care (see ACOG’s policy statement). A rape victim was not given emergency contraception upon arrival to an emergency room. A mother of two was refused emergency contraception, leading to an unwanted pregnancy. A woman with a life-threatening blood clot in her lungs (likely brought on by the pregnancy) was refused an abortion and as a result was transferred to another facility.

When you’re a doctor, it’s not about you. It’s never about you. It’s about your patient. It’s about the person in front of you who has placed her health and life in your hands. If someone comes in and asks you to take care of her, you take care of her. It might take 5 minutes, it might take 5 hours. You might be alone at your office until midnight getting her help because you don’t have someone to whom to transfer care. You never abandon your patient. I once stayed 12 hours after my (24-hour) shift was over because a woman for whom I was responsible needed to be taken care of and I couldn’t leave until I could safely transfer her care to another provider. That doesn’t make me a martyr, a saint, or even special. That makes me a doctor.

There are basic ground rules when you accept the responsibility of calling yourself a medical professional. You take care of your patient, and if you can’t you find someone who can. I am not saying that anyone should be forced to provide abortions or contraception if they do not wish to, excepting in emergent cases for which no other qualified provider is immediately available. I do believe that all options should be offered to all patients in an unbiased way, and a speedy referral must be made if the clinician cannot provide the services. In matters where time is of the essence (such as emergency contraception and oral contraceptive refills), clinicians or pharmacists should have someone else on site who can provide the needed services. Clinicians who do not provide birth control or abortion services need to have a colleague on-site who does, and should inform all patients prior to seeing them that they will not receive those services from them.

Anyone who is unable to abide by these rules should take a job in which they will not be confronted by these dilemmas. There are plenty of jobs in which this is not an issue. Gynecologists can specialize in urogynecology, for instance. Nurses can work in nursing homes or in surgical suites. Pharmacists can work at a nursing home pharmacy.

The bottom line is that if you can’t provide the services patients need and to which they are entitled, you need to find another job. The needs of the woman in front of you outweigh your conscience as a provider. Every time. Your preferences do not matter. Ever. It’s not about you. Ever.

8 Responses to “On Conscience Clauses and Provider Privilege”

  1. Dee July 7, 2010 at 2:40 pm #

    I can sympathize with the religious beliefs of caregivers, but I’m upset by the notion that several of them refuse to even refer the patient to someone who can help them. Ok, you won’t provide contraception b/c it violates your religious beliefs, you can’t me point your patient to someone who can provide these services?

    I have two examples from my life about this issue. I live in a very poor city, consisting mostly of poor people making minimum wage, many of whom don’t have a firm command of the English language. This city has two hospitals that I know of, and both of them are Catholic. A girl my sister works with was refused birth control (even the prescription) at one of these hospitals. I’m sure this girl doesn’t even know that there is a Planned Parenthood in our city (most people aren’t aware of its existence, especially first generation immigrants). That girl, as far as I know, had to do without the pill (I never met her, and my sister didn’t know about the reproductive services in our area any more than her co-worker did).

    The second case is my sister. I went to a doctor in NYC, and obtained that 3-month birth control pill, Seasonale. I obtained three months’ worth of pills for $50 b/c my insurance covered most of it. My sister then went to her doctor and tried to get her own set of 3 month pills. Hers cost $200, I believe. That’s most of her paycheck. Even though it is technically available to my sister, it’s practically very difficult for her to obtain birth control due to its high cost. And, yes, she had to go out of town to find a doctor who would prescribe the pill to her, as did I.

    Finally, I will say this. If my sister or I get pregnant, and the pregnancy goes badly, we will be driven to the nearest hospital(s), and neither of them will terminate the pregnancy to save our lives. The same goes for all the women in our town.

  2. Shayna July 7, 2010 at 11:56 pm #

    I agree – if you can’t do the job, then pick a different profession. If it doesn’t have something to do with my physical health, then these doctors, nurses, and pharmacists have no business denying reproductive healthcare to me.

    In studying for the CPA exam the ethics governing the accounting industry – particularly post-Enron have been drummed (and drilled and stapled) into my brain. The laws are meant to protect the shareholders of major corporations from fraud committed by management, and taxpayers from tax fraud. Even if I could benefit tremendously from my client’s tax fraud – even if I disagree with a tax statute, and think a client should be able to take an extra deduction – I cannot aid and abet it without suffering dire consequences. Similarly, regardless of a medical professional’s personal beliefs, it’s still their sworn duty to provide medical care.

  3. Not Guilty July 8, 2010 at 12:25 am #

    As an atheist, this sort of thing sends me into a rage. I just want to live my life, and that means NOT having the religious beliefs of others imposed on me. This sort of thing isn’t legal in Canada, but in the small town where I go to school, there is a doctor who won’t give birth control to unmarried women. It is totally illegal, but it is impossible to get a family doctor in the town, so women have to go to the free clinic, which will only help them until they are 25. So then what? When a woman is trying to be “responsible” (I use the word loosely) and prevent pregnancy, what is she supposed to do when thwarted by religious lunatics? If I had a pharmacist refuse me BC or Plan B I would have an absolute shit fit, such that the only way to get me out would be with what I went in for, or in handcuffs. Maybe the next time I venture south of the border I’ll go in and ask for some, just to see what happens. It’d be a fun day…

  4. nycprochoicemd July 8, 2010 at 3:22 pm #

    Thanks to all for your comments. I can’t even imagine living somewhere where the only option was a hospital that refused to provide necessary, and at times lifesaving, care.

  5. Katherine Kramer July 13, 2010 at 12:29 am #

    As an ob/gyn physician and abortion provider, I’m very upset when I hear that a pharmacist refused to fill a script for birth control. My training experience has also led me to question the provisions which allow residents to opt-out of abortion training for “moral reasons”. I once thought that no one should be trained in abortion procedures if they feel personally uncomfortable, I now believe that abortion training should be a requirement for all residents for many reasons. In more than one case, I’ve had to use the techniques used in abortion to save a woman who was bleeding heavily. Recently, in our training program, we had one male resident who was anti-choice and anti birth control. Patients complained and he was eventually fired.

  6. SarahC July 19, 2010 at 7:28 pm #

    Refusing to provide services because of personal beliefs is an abuse of power, and entirely unacceptable. It’s not as if eventually having to perform or dispense X was entirely unexpected.

    I work with other people’s horses on a fairly regular basis, and my rule of thumb is that, unless I’m asking to do something illegally abusive to the animal, I treat their horse the way they want me to, with the expectation that they’ll do the same in regards to mine. I have physically struck animals because of this, even when it went against my code of ethics. What kind of sick system do we live in where people have more control over how people handle their livestock than over the care of their own bodies?

  7. Mark Daugherty March 21, 2011 at 3:48 pm #

    Hello, @NYCprochoiceMD! My name is Mark Daugherty. I am studying to be a nurse in Peoria, Illinois. I am in the beginning stages of writing a research argument essay on doctors denying health care to clients that contradict their beliefs and why it is wrong. I was wondering if you could contact me and exchange information so I can cite your blog posts as references in my essay. I hope to hear back from you!

    Best regards.

    Mark Daugherty

  8. Divine Oubliette August 29, 2011 at 9:54 pm #

    What if providers were forced to make a referral for that patient because they choose not to treat them due their a conscious clause?

    I think that’s how it works in the UK, a doc can refuse to give you a referral for an abortion if they are anti-choice but they have to refer to another doctor who will give you an abortion referral. The law forces them to refer you to someone who isn’t anti-choice if they want to use the conscious clause.

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