Are Conscience Clauses Ethical?

birth-control-pillsI know that the headline of this post sounds like an oxymoron, but it’s not. Arizona recently passed a law that allows health care workers and pharmacists to refuse women access to reproductive health care if they feel that it goes against their conscience. The state’s bill is no different than the federal guidelines that say the same thing. If a pharmacists feels that it is immoral to fill a prescription for birth control or emergency contraception, they can do so. And if a doctor feels that it’s immoral to prescribe birth control to a woman, they can do so. USA Today has a story of one doctor who did just that.

Faced with a request to give an unmarried female patient a prescription for birth control pills, Dr. Michele Phillips looked to her conscience for the answer.

“I’m not going to give any kind of medication I see as harmful,” said Phillips of San Antonio. The drugs would not protect her patient from “emotional trauma from multiple partners,” Phillips reasoned, or sexually transmitted diseases. “I could not ethically give that type of medication to a single woman.”

Which brings me back to my question: are conscience clauses ethical? I don’t think they are. If I go to a pharmacy to fill a prescription, the pharmacist should fill the prescription – that’s their job. If I ask for an over the counter medicine like Plan B, they should give it to me – no questions asked. If I, Goddess forbid, were to get raped and wind up in an emergency room, they sure as hell better give me emergency contraception if I ask for it. It’s not the business of doctors, nurses, or pharmacists to impose a sense of morality on the world. If that’s what they want to do for a job, they should have gone into the ministry instead of the health care industry.

The USA Today article offers a different point of view.

Bioethicist Holly Fernandez Lynch said consistency is crucial to prevent patients from facing discrimination based on race, religion or sexual orientation.

“A consistent objection to a service, I think, is totally appropriate as long as there is someone available to provide that service at a reasonable distance,” said Lynch, author of Conflicts of Conscience in Health Care: An Institutional Compromise.

But, she acknowledged, “the phrase ‘reasonable distance’ is really a difficult one to figure out.”

While larger communities and hospitals have the luxury of a range of practitioners, conscience quandaries are trickier in smaller communities, said Leslie LeBlanc, managing editor of The Journal of Clinical Ethics.

“It’s a very difficult question because you can’t compel someone to do something they think is morally wrong and, by the same token, clinicians make a promise to help people in need,” said LeBlanc, who attended the bioethicists’ meeting.

By taking an oath to “do no harm,” a doctor has an ethical responsibility to do whatever is in their patients’ best interest. Birth control is in a woman’s best interest – it puts the control of her reproductive destiny in her own hands. That same ethical obligation applies to a pharmacist. If you don’t want to dispense emergency contraception, go into some other line of work. I don’t want to build bridges for a living, so I’m not an engineer. I don’t want to spend my days roping cows, so I’m not a rodeo cowgirl. I do love to write and get up on my soap box, so I blog.

What’s your opinion? Should health care providers be allowed to deny medical care based on their moral beliefs? Or do conscience clauses violate ethical codes of behavior?

Comments

  1. PhilosopherP says:

    I teach medical ethics — and this one is pretty tricky.

    On one hand, the patient and doctor — together — should be the ones making decisions about medical care. If they can’t agree, generally the patient can go elsewhere and the doctor has a duty to permit that.

    Doctors do not have to do procedures they think are immoral — abortion is the most common — but this isn’t limited to abortion.

    Women have the right to go elsewhere.

    In terms of pharmacists — they still shouldn’t be required to do the equivalent of an immoral procedure — IF (and only IF) the patient can go elsewhere. The trouble comes when the pharmacist is the only one in town — or if the medication is so time sensitive that the patient can’t come back later to get it…

    at that point, I don’t see why the pharmacist’s PERSONAL ethical opinion should take precedence over the patient’s decision about her healthcare — especially when the patient and her doctor have already decided that it is what is medically best for her. In such a situation, it seems that the pharmacist’s ONLY grounds to object is if they (probably he… no?) suspect a medical mistake, not an ethical one.

  2. Okay, I knew “consience clauses” apply to abortions and plan B, but birth control pills? Our state (and federal) government never ceases to kick their archaic agenda up to a whole new level.

    • Catherine Wood says:

      Perhaps you are unaware Helina that birth control pills cause spontaneous abortion. Any doctor who does not tell this to a patient when prescribing them is doing a disservice to his patient and profession.

      It never ceases to amaze me that people form archaic opinions based upon a complete lack of knowledge.

      • Eh, what? Even Plan B doesn’t technically cause an abortion (though it does kill a zygote) because it kills the zygote before it implants in the uterus. Any sexually active woman’s body will do that to most zygotes that get produced, so I don’t really see the objection there.

        But normal birth control, or at least the classic Pill, stops women from ovulating. All that means is that the egg can’t get to where the sperm are. It doesn’t kill anything; it works essentially like a condom, except it’s (tricking the woman’s body into) blocking the egg instead of the sperm.

      • Sorry, you are wrong. Birth control pills do not cause spontaneous abortion or miscarriage. Get your facts straight.

  3. I want to know if these pharmacists have ever asked a man presenting an Rx for Viagra or similar meds for proof that his is married before filling. Otherwise condoning sex outside of marriage, no?

    If a pharmacist doesn’t want to be compelled to fill an Rx she/he is morally opposed to, she/he should consider a whole other line of work.

  4. My theory on the matter is this:
    If you own the pharmacy, you should be able to what you damn well please. If you don’t want to dispense BC or EC, then fine, don’t. However, if you work for me at my pharmacy and refuse to dispense it, I should be able to fire your ass. Here’s my analogy: if you’re vegetarian, you can open a vegetarian restaurant. You can’t take a job at my steakhouse and then refuse to serve steak based on an ethical problem with meat. If you don’t like it, get out of the business entirely. I have a feeling that pharmacy owners, large and small will have a different view of conscience clauses if denial of services meant an actual difference in wages–the owner lives off profits whereas the pharmacist draws a salary which is unaffected by the sale of BC to sluts, or lack thereof.

  5. But doesnt the clause also state that the provider must refer the patient to either another pharmacist or physician who will perform the services?

  6. I’m not sure if marital status is a protected class in Arizona but in states like California and Oregon, this could be considered discrimination (I believe although I am no legal expert). Morality is not black and white and others’ personal morals should not have an impact on the choices that I only should be able to make about my personal health. What has our country come to and fought for to now give people the power to deny birth control to a single woman who is making responsible choices by asking for it in the first place? This is almost as bad as the judge who refused marriage to an interracial couple for fear that their children will be outcast. 

    What I fear will happen next is something as drastic as a doctor working in an ICU of a hospital not allowing a family to remove life support on a brain dead patient because it is against their morals.  Or an obstetrician denying an emegency cesarian because anything but natural birth is against their morals.  Where is the line drawn?

  7. Besides the fact that it should be nobody’s business except the patient and doctor which medication they are prescribed, what about single women who are taking birth control for reasons other than contraception??

    Personally I was on it from the time I was 20 until about two years ago (age 28) when I started trying to get pregnant, because of terrible periods and symptoms (I have endometriosis and polycystic ovaries, and birth control pills are the best way to keep the awful symptoms at bay). For several of the years I took it, I was not sexually active at all, but I *needed* that medication.

    Like others have said, if you don’t want to dispense medication to patients, prescribed by a doctor, perhaps you should re-think your profession.

  8. I am a medical student and a member of Medical Students for Choice.

    I strongly believe in conscience clauses and plan on refusing to perform certain procedures and to dispense certain medications when I am a physician. I think every physician follows her conscience, and am afraid anti-choice activists are using this important part of medical ethics to refuse to provide services that are in the best interest of the patient.

    I plan on refusing to perform unnecessary procedures that are requested all the time as an ob/gyn. I will not perform any genital mutilation, male or female. This includes any routine newborn male circumcision, or elective vaginoplasties. This of course does not extend to any medically indicated procedures, which would be in the patient’s best interest.

    I will refuse to do labor inductions because a mother is sick of being pregnant or because I am going on vacation. I will refuse to do non medically indicated cesarean section because a mother is afraid of the birth process or wants to have her baby on a certain date, or because I want to get home in time to have dinner with my family on a day I am being paid to be on call.

    I think practitioners that are truly ethical do not use conscience clauses as an excuse to deny medical treatments to their patients or clients because of some idea that premarital sex is immoral. It is easy to find work in an area that does not involve refusing to provide necessary medical care. Most of these people who are refusing reproductive health care want to make an issue out of their refusal to control women’s sexual autonomy, not to support their own ethics, and it’s a shame.

    There are two students in my medical school class who have stated they will refuse to prescribe birth control. Both identify as Catholic. One was more than happy to take handfuls of condoms our club was passing out for when he has sex with strippers (I wish I was kidding). He said he is using them for disease prevention, not birth control, so he is not a hypocrite.

    I hope he goes into radiology, or urology.

    The other is a Jesuit priest. He is planning on going into psychiatry, so most likely won’t be in a position to be a birth control prescriber often. He is also honest and out in regards to his homosexuality, and is an activist to change the Catholic position on homosexuality. So, he thinks some rules are meant to be changed.

    The point of these two stories is to say, ethics mean different things to different people. Physicians and other health care practitioners are too diverse a group to force into one group of practices. However, we can encourage responsible application of conscience clauses and try to make sure essential health care does not get refused in the process.

    • ”He said he is using them for disease prevention, not birth control, so he is not a hypocrite.”

      The man speaks truth.

  9. freewomyn says:

    WOW! Thanks for all of the great comments – you’ve really given me a lot to think about on this issue.

    @ PhilospherP – Your point about being the only provider in town is a very real issue for most women in the US. 87% of American women live in a country that has no abortion provider. I’m not sure what the statistic is for birth control access, but I would venture to guess it’s in the same ball park.

    @ Rachel – In Arizona, a pharmacist does not have to facilitate a referral if they refuse to fill a birth control or EC prescription. I think that the federal guidelines say that facilitation is required. But so far in AZ since the conscience clause passed, Planned Parenthood is reporting a marked increase in the number of women calling in for emergency contraception because they haven’t been able to get it at a pharmacy.

    @ Anne – you raise some very valid questions, especially the one about life support. I personally do not want to be on any machines. If I can’t breath and function without the aid of technology, it’s time to pull the plug. I seriously hope that I don’t end up in a hospital where some doctor or nurse has an ethical problem with my medical wishes. If I’ve got it in writing, then they need to put their own personal feelings aside and pull the plug. The patient should have the final say.

    @ Sarah – excellent point! Lots of people take birth control for acne, regulating heavy periods, treating PCOS, and other health reasons.

    @ MomTHF – all valid arguments. I think it’s awesome that you are unwilling to schedule births to facilitate your schedule. Babies come into this world when they are good and ready. Your classmate who takes condoms for disease control really blows my mind. I think the Catholic church has something to say about promiscuity, and it ain’t just for the ladies.

    • “I think the Catholic church has something to say about promiscuity, and it ain’t just for the ladies.” Please read the Catechism, Humane Vitae and PJP II’s “Theology of the Body” if you want to understand the Catholic Church’s position on sexuality. Because you’re right the ideas around promiscuity “ain’t just for the ladies.”

      BTW, the Church isn’t morally opposed to taking birth control for medical reasons. Just for reproductive reasons (for single and married couples). I don’t think there’s a point in arguing the Church’s point since it is often something people just don’t care to understand.

      It’s interesting. The person who is for choice and a medical student presents situations where he/she hopes to be given a choice–and I hope this person is “tolerant” of people who have different choices; like not wanting to distribute Plan B because he/she truly believes that a newly conceive life, how ever early in the stage of development is a human being that has inalienable rights.

      Obviously, I’m pro-life who agrees with this clause. We’ve seen cases of colleges and hospitals forcing people to participate in abortions to graduate/keep their job. I think it’s intolerant (in PC lingo) to force someone to commit murder–even if you don’t think it’s murder. Just go find another line of work? I think anyone here would like it if the reverse were true. If pharmacists routinely did NOT hand out plan B and the ones that wanted to were told to go find another line of work? Pro-choicers would call that discrimination.

      I do agree if a business is privately owned then the owner makes the call. In the public sector, however, this issue is being forced upon pro-lifers. And that is wrong. It’s discrimination. The public is everyone–not just a few.

  10. Mrs. Mastro says:

    Here is my thinking on this subject:

    If you are a member of almost any other profession, your personal ethical concerns are always superseded by the rules that govern your job.

    If you are a police officer who believes it is morally wrong to arrest non-violent drug offenders, you can’t refuse to do it if you catch them. You would then be aiding and abetting a criminal and you would lose your job (or worse). Even if you think a particular act should or shouldn’t be illegal, you don’t get to decide, no matter what your ethical position is. You have to enforce the law, for good or ill.

    And…it is especially important to point out that there isn’t a big ruckus over doctors refusing to remove gallbladders or do appendectomies. Instead, what is at stake is the degree to which doctors and pharmacists have the right to interfere with the bodily autonomy of women.

    Given this dimension, the question becomes always already one of the degree to which they should have the power to use their professional position to control my body. This means that their ‘morality’ is simply one more weapon they can use to oppress women. It is a cheap excuse used to perpetuate women’s subjugation.

    Just like you shouldn’t be a Magistrate/Justice of the Peace if you don’t want to perform marriage ceremonies for mixed-race couples, you shouldn’t be a doctor if you don’t want to prescribe/fill prescriptions for birth control.

  11. OK, so Mrs. M, would you extend that logic to say that you shouldn’t be a JOP or city clerk if you don’t want to hand out marriage certificates to same-sex couples? I vote yes.

  12. Mrs. Mastro says:

    Freewomyn–If same-sex marriage is legal in your jurisdiction, you shouldn’t be able to refuse to perform a marriage ceremony for a same-sex couple any more than you should be allowed to refuse to do so for a mixed race couple. There are some jobs that just don’t leave room for personal morality, IMHO.

    Refusing to perform unnecessary c-sections is different than using your personal beliefs to influence my morality. There are branches of medicine you can go into or places you can work as an OBGYN if you don’t want to perform abortions. Fine. But a pharmacist who doesn’t want to dispense birth control should work for a Catholic pharmacy, or suck it up and deal.

    I don’t visit my local Walgreens because I am interested in the beliefs of the pharmacist–In fact, I expect a degree of professional detachment that precludes an assertion of the pharmacist’s rights over mine. If I go to St. Joseph’s hospital pharmacy (a private, Catholic facility), expecting the same, then I am doomed to disappointment.

  13. This writer suggests that nurses who receive the benefit of a government license for practice should provide care the public deems acceptable. True conscientious objection is on the order of civil disobedience, undertaken with the expectation of severe consequences:

    http://nej.sagepub.com/cgi/pdf_extract/14/3/277

  14. I read the article and the comments here and I’m sad. It seems that many, many Americans no longer believe in liberty. They seem to believe in government coercion. I as a citizen should not be able to force (especially by government force) someone else to perform a service for me whether it’s medical or any other service. This is the foundation on which our government was built. If a pharmacist doesn’t want to dispense a certain drug, for whatever reason, then they shouldn’t have to (and if their employer doesn’t approve, then the employer should be able to fire them). And if a doctor or nurse doesn’t want to perform some service, they shouldn’t have to. If I want them to perform a service, then I need to find some way to entice them to do it (usually through paying them). It’s what’s called “voluntary exchange.” If the government can force doctors, nurses and pharmacists to do certain things against their will, then we no longer live in a society based on liberty. This is the problem with the so-called “right to medical care.” It is fundamentally different than the right to free speech and the other rights in the Constitution.

    In the article, it says “It’s not the business of doctors, nurses, or pharmacists to impose a sense of morality on the world.” But they have no power to force you to conform to their morality. They can only control their own behavior and not help you go against their morality. What the author is proposing is that the government impose its sense of morality on doctors, nurses, and pharmacists. And, the government really does have the power to do so. Imagine if the government wanted to force you to help someone else do something immoral, say, help a less qualified man get a promotion at the expense of a more qualified woman (or, if you’re pro-choice, if the government required you to actively stop a woman who wanted an abortion from getting one).

    You might think some of the decisions of a doctor, nurse or pharmacist are outrageous, but you are not the one who has to live with the consequences of those decisions. A pharmacist who refuses to give out a certain type of contraception (or any contraception) or who bases it on who the person is may go out of business (or get fired by their employer). But they are the ones who have to live with that consequence, not you or me. Same with doctors and nurses.

    Some say that doing abortions is part of being a doctor, or giving out contraception is part of being a pharmacist. Who are you to decide? And who is the government to decide? And, Mrs. Maestro, a minister should be free to marry or not marry anyone they wish. I know ministers who won’t marry a couple if they think the marriage will be unhealthy. They should not be forced to participate in something they think will be harmful to others. Police are really no different because they generally work for someone else. So, they have to do what their employer (ultimately the taxpayers) tell them or not work as a police officer in that particular community.

    The defining concept here should be liberty. We as a nation seem to be losing sight of that.

  15. Jessica Metaneira says:

    That is disgusting. Just disgusting.

    It’s not their place as a pharmacist to make other people’s medical decisions for them. They have no right to decide what that woman may do with her life or whether she can have sex free of the danger of pregnancy. It’s not their body, or their reproductive system, and to act like you own some stranger’s life and body is a disgusting violation.

  16. Well, let’s see….I’m a Christian and I’m an RN. I work in a Catholic hospital. When, and I say ‘when’ because it will happen, our hospital is forced to provide services, such as administering abortion inducing drugs or care of a patient having received such, I will not administer these drugs nor care for patients who require observation after receiving such drugs. You see, if I do not assume the care of such patients then I can not abandon them (as some would argue), and if I am told I must administer abortion drugs or care for a patient who has had them, I will refuse. I will resign right then and there. I will be done with nursing. For you, nor no one else will EVER convince me to be a part of what I believe to be wrong, regardless of the field I have chosen to follow. And having been a nurse for many many years, no one can say that I must comply with a mandate that comes ‘after the fact’. I only have to answer to one true God (ahem, NOT a goddess as you proclaim) and not YOU.

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