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.