MEDICAL ETHICS

Conscience and Care

Ethical Guidelines Offered for Deciding If Medical Services Can Be Refused

A physician’s reluctance to prescribe palliative sedation to a dying patient or a pharmacist’s refusal to provide emergency contraception creates a seemingly intractable conflict that pits professional responsibility to patients against individual moral convictions.

Graham Ramsay

To help doctors and other health professionals resolve moral dilemmas about legal and beneficial care, Brock proposes the “conventional compromise” as a way of balancing professional obligations with moral integrity.

Despite the high-stakes tension, it is possible for doctors and other healthcare providers to act on their own conscience without shirking their duties, argued Dan Brock, director of the HMS Medical Ethics Division, in a recent paper. Such conscientious refusals are compatible with professional medical and pharmacy obligations under three conditions, Brock proposes: The doctor must inform the patient about the medically relevant option. The physician must refer the patient to a willing colleague. And the referral must not impose an “unreasonable burden” on the patient.

Brock calls this conditional trinity the “conventional compromise” and offers it up as a guide both for public policy and for individual decision-making by physicians, pharmacists, and other healthcare providers.

“The conventional compromise helps balance professional obligations with moral integrity,” said Brock, the Frances Glessner Lee professor of medical ethics. “There are good reasons to try to permit people to act in accordance with their conscience. Doing so respects their moral integrity. But that’s not an unlimited right. A physician and pharmacist are acting in professional roles regulated by the state. They have obligations to their patients or customers.”

The majority of U.S. physicians seem to endorse Brock’s position, observed general internist Farr Curlin, assistant professor at the MacLean Center for Clinical Medical Ethics at the University of Chicago. Most physicians in a survey believed physicians are obligated to present all options (86 percent) and to refer the patient to another clinician who does not object to the requested procedure (71 percent), Curlin and his colleagues reported last year in The New England Journal of Medicine.

Curlin agrees with the 18 percent of physicians in the survey who rejected the referral option (the other 11 percent were undecided). In some cases, such as abortion, “such referral makes them complicit in a gravely immoral action,” Curlin told the President’s Council on Bioethics last month. Curlin questions whether professional obligations include practices that are ethically controversial.

In March, Curlin convened a conference at the University of Chicago Divinity School featuring Brock and seven other scholars to discuss the role of the clinician’s conscience in the ethical practice of medicine. Several of their papers, including Brock’s on the conventional compromise, were published online Aug. 28 in Theoretical Medicine and Bioethics.

Professional Responsibility
Individuals may frequently disagree on moral questions, even within the same religious tradition, but respect for an individual’s moral integrity, no matter what the content of their moral beliefs, is a fundamental value, Brock said. Even so, other values will sometimes be more important. Society and the professions may legitimately require action that violates an individual’s sense of integrity, he said, such as the way social justice laws would trump a white doctor’s refusal to treat black patients based on the doctor’s belief that mixing of the races is wrong.

The conventional compromise applies to legal and professionally accepted actions or practices that an individual practitioner believes to be deeply immoral, whether by reason of religious or secular moral commitment, Brock said. In fact, the compromise assumes the willingness and ability of convenient colleagues to cover the legal and beneficial medical service when an individual professional opts out for a justified refusal.

Abortion is the most obvious and prominent example, but conscientious refusals cover less publicized issues, such as growth hormone for enhancement rather than treatment, assisted reproductive services for unmarried couples, the HPV vaccine for young girls, and palliative sedation. More recently, controversy has ignited about refusals by doctors to prescribe emergency contraceptives, and pharmacists to fulfill valid prescriptions or sell them on demand. The actions “had greater consequences for patients,” Curlin said, “because emergency contraception only works if taken within 72 hours of sexual intercourse.”

Degrees of Separation
The information and referral requirements bestow a lesser degree of complicity, said Brock, citing as an example the diminishing degrees of complicity in innocent Iraqi civilian deaths on the part of Donald Rumsfeld, who planned and executed the war; the senators who voted to authorize President Bush to initiate the war; and ordinary U.S. citizens, whose tax dollars have paid for the war.

The physician or pharmacist who does the informing and referring can also recommend against the procedure or product and make it clear why she believes it to be immoral. “The crucial point is that the physician is acting in the role of a medical professional,” Brock wrote in his paper. “The profession’s duty overrides the physician’s claim of moral integrity to avoid any degree of complicity.”

Almost every state explicitly allows some professionals or institutions to refuse to provide or participate in abortion, contraceptive services, or sterilization services. Federal law allows healthcare institutions and providers to refuse to participate in abortion services on the basis of their religious or moral beliefs. A proposed new U.S. Health and Human Services (HHS) rule expands the right of refusal to limit information and access to the entire range of healthcare services, including treatment of infertility, depression, drug addiction, HIV/AIDS, and more. The comment period for the proposed HHS rule ended Sept. 25.

Some states have gone further, permitting refusals without conditions. But according to Brock, “Failure to provide a legal and medically beneficial product or service without satisfying the three conditions of the conventional compromise should be grounds for professional discipline and civil action.”

In contrast, a model law signed into law last month in California mandates that terminally ill patients be informed and counseled in all available legal and ethical end-of-life care options and that physicians who do not wish to comply with a patient’s choice refer or transfer the patient to another provider.

On campus, the topic of conscientious refusal rarely surfaces above issues of confidentiality, conflicts of interest, end-of-life issues, genetics and genetic testing, and others in the required first-year ethics class and in the lottery of case-based learning curriculum, say Brock, who teaches the HMS ethics class with colleagues, and Ron Arky, the Davidson distinguished professor of medicine and master of the Peabody Society. “Each year, a student or two will not participate in anything that sounds like an abortion,” said Arky. “We respect those students’ [refusals]. If these students seek a residency in obstetrics, they choose an institution that prohibits abortion.”

—Carol Cruzan Morton

Conflict Disclosure: The authors declare no conflicts of interest.

Funding Sources: No external funding was used for this study.

top