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When Can a Doctor Refuse Care?

Kendracampbell572x722Kendra Campbell -- This morning, an article in the Baltimore Sun really caught my eye. The article described a new pharmacy opening up in Virginia that has decided not to offer any form of birth control for sale. I was shocked to find out that this pharmacy is actually located very close to a town that I lived in during my undergrad years, and hence the article really hit close to home for me (literally).

The debate over pharmacists’ right to refuse to sell birth control pills based on religious views has been going on for years now. Some states have passed laws defending this right, while others require pharmacists to offer birth control, regardless of their religious beliefs. For years, the American Medical Association (AMA) has been battling the American Pharmacists Association's policy, which states that pharmacists should not have to “engage in activity to which they object.” The AMA has voted to support legislation requiring pharmacists to either fill prescriptions or refer the patient to a pharmacy that will.

I support the AMA’s actions to protect patients’ access to pharmaceuticals, but the issue is much broader than just drugs. What about a patient’s right to have access to medical treatments? What about a doctor’s responsibility to provide care to all patients? This is, of course, a very heated debate, and is a sensitive subject for many.

The Differential’s Thomas Robey wrote an article that touched on the subject of a physician’s responsibility to provide therapies to patients. The debate is very old, and I can only offer a small amount of insight in this short article. But, it’s something that I feel strongly about, and I wanted to give an opportunity to others to air their opinions on this important subject.

In the AMA’s Code of Ethics, it states that a physician must “refrain from denying treatment to your patient because of a judgement based on discrimination.” But, the Code of Ethics also states that, “when a personal moral judgement or religious belief alone prevents you from recommending some form of therapy, inform your patient so that they may seek care elsewhere.”

Here comes my very provocative question. Where is the line between denying a patient care, such as prescribing birth control or even offering an abortion, and denying a patient care because a personal moral judgement or religious belief prevents you from doing so? If I deny a patient care because they are black, is that discrimination? Most people would say yes. If I deny a patient an abortion because it violates my religious beliefs, is that within my right? Perhaps many people would say yes. But what about denying a homosexual couple access to in vitro fertilization therapy because your religion doesn’t condone homosexuality? Would this be considered denying care because of discrimination, or is the physician's right to deny treatment protected, because of their religious beliefs?

The waters are clearly murky. What do you think?

October 27, 2008 in Kendra Campbell | Permalink

Comments

Lots of statutory and case law make the case of two things needing to be satisfied:
1: the patient is not unstable/in emergent need of stabilization

2: you haven't already established a doctor-patient relationship with them

If you have already established a doctor-patient relationship, things get ticklish.

Posted by: Jared | Oct 27, 2008 9:16:34 AM

Nice article, Kendra.

Isn't interesting how these stories tend to get more traction in election years?

With regard to your questions, I think that the (AMA-guided) waters stay navigably clear as long as there are nearby providers who WILL provide the procedure. If I didn't want to do abortions in Seattle, I'd have a list of resources for my patients. Where the murkiness comes in is when there is no one else in the community, county, or even in the state who will perform abortions. Think of the teenager in rural South Dakota, or perhaps conservative western Virginia. It becomes even more complex when some states still make it illegal to transport a minor across state lines to have the procedure done.

And this complexity is exactly what the article you linked refers to. It doesn't matter if its birth control or the morning after pill. It's the same issue:

"If this emboldens other pharmacies in other parts of the state, it could really affect low-income and rural women in terms of access," said Tarina Keene, executive director of the Virginia chapter of the National Abortion Rights Action League.

I think the AMA guideline is a time-tested band-aid for what I believe to be a still broken system. Let's see what November 4 brings; the policy surrounding this issue could continue to be ever-improving, or take a troubling never-improving turn.

Posted by: thomas | Oct 27, 2008 4:42:49 PM

I would ask this: Are we going to become a profession where you MUST do whatever a patient asks of you? Are we only going to admit students to medical school (or other health professions) who will perform abortions, prescribe the morning after pill, or assist a homosexual couple to have in vitro? If that begins to happen (and I know WOMEN applicants who have been asked the question, "Do you object to performing abortions?" in their medical school interviews), what happens to the PATIENTS who object to seeing doctors who consent to doing these things? Can we not have all beliefs represented? I realize rural areas are a problem but realistically, that isn't the major issue.

Posted by: Mary | Oct 28, 2008 12:44:45 PM

If anything, your status as a doctor means you should never, ever, do anything you consider unethical. Sure, don't be a tool about it and help patients seek care elsewhere, but who has the right to force you to break your ethics? Not the government, and certainly NOT the AMA. And Kendra, I wouldn't consider comparing those of us who (respectfully and kindly) object to abortion with racists who wouldn't treat black people to be a very feasible metaphor.

Posted by: Jessica | Oct 28, 2008 1:30:59 PM

Jessica,

That's just it though.. they are indeed the same. Your object to abortion because of a belief... racism is the same thing, nothing more than a belief. The same for not helping homosexuals get pregnant. What your reasons for your belief are hold no bearing on the outcome. Either way, a patient is denied treatment by the doctor they came to see. And these scenarios aren't metaphors, they are examples... and very good ones at that. Most people make the mistake of drawing the line wherever they see fit and calling on others who cross it. But someone always crosses another's line at some point... .. always. You just have to accept that you must practice as you see fit, and others will do the same.

Posted by: Benjamin | Oct 28, 2008 2:13:35 PM

I really fail to see what the issue is. We are talking about elective procedures here: abortion for birth control and in-vitro fertilization. Refusing to carry out a procedure that without it would cause the patient death or disability is one thing, but simply causing inconvenience is another. It doesn't matter if there is not an abortionist in 1,000 square miles, physicians should not be forced to commit what many feel is murder for convenience issues. Along the same lines, we should not be forced to perform an elective procedure we feel is immoral, regardless of access issues.

Posted by: Joe | Oct 28, 2008 4:02:26 PM

I don't want to be irritating, and, as Joe says and you close with, Ben, in the end one should merely practice "as they see fit." But I still do not believe the two aforementioned situations are comparable. In refusing to perform certain procedures or to provide certain medications, your bias is not against the PERSON. There is no favoritism, no slight, no bias involved towards your patient. You consider an ACT or ACTION to be inappropriate... This is a far cry from a situation involving racism. Your objection isn't towards YOUR action, but against the patient! We're discussing legitimate ethical quandaries here... and I don't think anyone really believes that racial issues fall in that purview.

Posted by: Jessica | Oct 28, 2008 5:05:06 PM

Kendra - thank you for writing about and concisely summarizing the issue.

While I appreciate the right of the physician to maintain personal moral subjectivity in treatment, this should not be directed at certain patient populations and not others. In the example of the woman seeking in-vitro fertilization, the physician's action was discriminatory because it was based on the patient's homosexuality. Conversely, if the physician broadly doesn't offer in-vitro fertilization, because it conflicts with the physician's values, that right should be respected (as is argued for the pharmacist’s choice to dispense contraceptives). Otherwise we are in danger of setting a precedent where broad discrimination is acceptable as long as personal morals or religious beliefs endorse that discrimination (per the AMA). Thus, provision of elective procedures should be physician-based, not patient-based: if you don’t like elective abortion (or in-vitro fertilization, cosmetic surgery, etc), don’t offer it, but don’t discriminate who does and doesn’t get it based on non-medically related factors (race, religion, sexual-orientation, etc).

The problem of course, and a major tenet of this discussion, is when morals or religion justify discrimination in the medical setting, even when medical indication is apparent. It was mentioned by Joe that the examples given are of elective nature. True, but what of women prescribed hormonal contraceptives for acne or dysmenorrhea? The pharmacist that denies the prescription secondary to religious conviction disagrees with one effect of the drug despite a “morbidity/mortality” indication and absence of the proposed “pro-life” conflicting use. Does this same pharmacist refuse to dispense all pregnancy category D drugs to females of child-bearing age due to the possibility of contraceptive or abortive effects? (No is the answer). I suppose the pharmacist’s logic would be better supported if there were consistency in reasoning, rather than broad and presumptive discrimination based on unilateral religious/moral views. Either way, the outcome is in direct conflict with the healthcare provider’s primary role: patient advocacy.

Interestingly, this issue has now taken a turn that may be even more fundamental. It is possible that if one's morals broadly inhibit job function, it would behoove that individual to seek a different line of work. As Mary alluded to, physicians should not be at the beck and call of patient requests. Rather, we advocate medically. Abortion is tricky, I think, because it is not necessarily a standard of care. If it were to become one, than anti-abortionists would likely encounter a conflict of interest at some point. This is perhaps the logic explaining why Jehovah's Witnesses do not work in surgery (blood transfusion), observant Jews do not shop at non-kosher butcheries, and anti-assisted-suicide medical students do not attend OHSU. Of course I am speaking broadly (as there are always exceptions), but only to illustrate the point that avoiding the ethical dilemma is within one's own control. In many environments the decision is easy, as it does not involve the welfare of another. However, physicians have patients, whom seek medically appropriate advice and treatment. If patient advocacy is at odds with your morals, perhaps you shouldn't be a physician.

Posted by: Stephen | Oct 29, 2008 12:59:46 AM

Physicians need to first do no harm. Then they need to do their best for the interests of the patient. That being said, I would not deny someone of needed medical intervention. However, I can not personally be involved with any abortion because it conflicts with my views that everyone including an unborn child has the right to life.

Posted by: Bill | Oct 29, 2008 11:32:10 AM

I understand the reasons for refusing treatment, but there must be a line. How much is too much? Say it is a an abortion which you are against, but a life threatening emergency required such an act. What would you do? Deny treatment, and tell the patient to seek elsewhere and allow that patient to deteriorate, or give up your moral belief for the benefit of the patient?

Of course, if it were in the elective setting, where you have the luxury of time on your hands, appropriately denying treatment options responsibly, may be vindicated. When does it stop? Religions in general tell people to not kill, however in the medical community it is widespread knowledge that while we are able to cure and treat a wide number of conditions, new ones pop up which were never around before (because of our prescribed treatments). Statistics released by various medical councils all over the world will show you a significant number of deaths and morbidities are attributed to health care professionals. Will you stop prescribing because you may kill a patient albeit inadvertently? Because, quite frankly the stark truth is all doctors will kill patients at some point in their career. A bit too much warfarin here, a bit too much digoxin, beta blockers, morphine, too much O2 for a CO2 retainer, unaware of a drug allergy etc..

Those of you who have done terms in palliative care will know that it is usually treatment (especially opioids: morph, fentanyl etc.) which essentially will kill the patient. Will you deny this dying patient effective pain medications because it will kill them faster?

My belief is, sometimes you just have to sacrifice a bit, so that you may provide the best medical care for your patients, because if you don't, then just quit. Your interests aren't with the patients, they are with yourself!

Posted by: Kolin | Oct 29, 2008 3:18:59 PM

I think the only thing is for us to agree to disagree...because this type of debate undoubtedly goes on and on...

But it does generate another question...who decides the "social ethics" of our society anyway?...concerning us, is it just the governing body of the AMA or the government..etc... at any given moment? If you're talking about rights of the public, who has the right to force a physcian (who is also a member of the public), what to beleive? Just because i'm a doctor doesnt mean that I have to relinquish my rights (that doesnt come with the job description--and no matter how good of a person you are....it's still a job).

For lack of a better examples, actors dont take roles that go against their beliefs, chef's dont offer certain foods in their restaurants..etc..Physcians shouldnt have to perform certain said ELECTIVE procedures. And this, as jessica points out quite articulately, is not comparable to racism.

And for those of you who are advocating patient care above and beyond physcian resposibility....does that mean your patient can call you whenever he/she wants (whether or not you're on call) or come to your home? And would you be jumping to his every whim (because of course that would be putting the patient first...). I highly doubt it....why? because you are human and deserve to draw the line between your work and the rest of your life.

Posted by: FC | Oct 30, 2008 8:47:07 AM

If you have a physician/patient relationship, you may not abandon him. If, however, you have a conscientious moral objection to a treatment or procedure, you may refer that patient to a willing provider. A problem arises when there is no other. this has happened with a dialysis treatment center. the patient needed to travel to another community. Ethics is about boundaries as well as principles and values; the professional dialogue will continue - not as a failure of principles, but because these are true dilemmas.

Posted by: miriam piven cotler, Ph.D. | Oct 30, 2008 11:10:37 AM

OK, so do you have to show your marriage license to get your levitra or viagra?
I applaud anyone who holds true to their own moral compass, but please don't hide behind the untouchable golden shield of religion unless you are in agreement with every article of that religion.

Posted by: Kathleen | Oct 30, 2008 3:42:31 PM

Well you see, kathleen, the difference between performing the said elective procedures, as compared to not having to show your marriage license to get meds like viagra are because as a society overall, we clearly no longer care if a person has sexual relations outside of marriage ...even though at one time (even if it seems ages ago) it was considered a social taboo. The ones who did care have either died off, or are in the process....and very few younger people still advocate this publicly...So, no social push, no problem in getting the meds.

The difference here is that there is still a larger percentage of the population who disagree with the elective procedures we are talking about, both young and old. So, until they die off (i apologize for using the word so insensitively)....[because it is very unlikely to change a person's ethical views]...this argument will continue.

But then again, a new topic will probably surface...like the concept of cloning. Althuogh the majority of the population does seem to oppose it on some ethical level at the present time....there will be a time when those who oppose it will be called conservatives....its the nature of how ethics change when they are based on social trends...kinda concerning...

Posted by: | Oct 31, 2008 5:57:57 AM

'. . .Clearly murky.'

Heheh, nice.

Posted by: axolotl | Nov 2, 2008 9:55:36 PM

I personally believe that the religious points of view shouldn´t have nothig to do with the matters that affect all people. To me it´s not a valid reason to refuse giving medical care to people that need it because of religious or cultural points of view, the human being is all that matters when it comes to health sciences and health care, no relious belief should be an obstacle when dealing with people that is trying to keep themselves safe of having unwanted pregnacies, nobady should refuse giving relief to a terminal disease, giving support to poeple that has no option to overcome an illness even if it implies eutanasy, law has been really selfish when taking this matter into account and many debates have been placed because of it... Medical sciences and health care should considerate the life`s quality as their main priority and refraining of going around this matters is quite unresponsible.

Posted by: Diego Rodriguez | Nov 3, 2008 12:19:54 AM

This is a really a simple question and not murky at all. First, no doctor should be forced to perform an abortion if they oppose it because of religious beliefs. Likewise, no doctor should be forced to perform in vitro fertilization if the oppose it because of their religious beliefs. In this case, the doctor didn't oppose in vitro fertilization at all. If the doctor is willing to perform it, then s/he should be willing to perform it for everyone who requires it. Withholding a service because you are pre-judging the recipient of that service is called prejudice. It is discrimination. If that doctor thinks that being a Muslim is morally wrong, should that doctor be allowed to withhold care? If not, why should s/he be allowed to do it if the recipient is a homosexual?

Posted by: kathy | Dec 5, 2008 11:54:00 PM

Abortions and religion aside. How can a life preserving physician have the right to deny a patient treatment. For instance, dialysis. How is it possible that a physician can deny 60 year old one year dialysis patient treatment in his city? leaving the patient to travel for milesss 3 days a week to have life? No return call, no comment just declines to treat the patient.

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