Broader conscience clauses would expand physicians' right of refusal

Legislators in at least nine states this year have proposed sweeping legislation granting physicians and other health professionals the right to refuse to provide any medical service on the grounds of conscience, without fear of firing, discipline or liability. The proposed legislation also would give hospitals and third-party payers the same conscience rights.

Many state medical societies long have supported the concept of conscience clause laws when they have been related to abortion and other controversial services. However, societies in several of the states where legislation is pending are either neutral or speaking out against the push to extend the principle more broadly.

The bills, which are based primarily on a model crafted by the conservative Chicago-based Americans United for Life, are one aspect of the larger debate over how best to balance health professionals' conscience rights and patients' access to care. That debate has heated up recently after some pharmacists refused to fill prescriptions for the emergency contraceptive pill, also known as Plan B or the morning-after pill, because they believe it is a form of abortion.

If bills pending in Alabama, Michigan, Missouri, Rhode Island, Tennessee, Vermont, Washington and West Virginia pass, the controversy might only deepen. A similar measure narrowly failed in South Dakota last month.

"The legislation that's on the books mostly protects physicians who don't want to perform abortions," said David Stevens, MD, executive director of the Christian Medical & Dental Assns., which supports the expanded laws that are being referred to as "health care rights of conscience acts." "Very little of it protects other types of health care workers with regard to the morning-after pill and other new technologies in the pipeline."

Dr. Stevens said the proposed legislation's broader approach was necessary, given the moral objections some have to human embryonic stem cell research, physician-assisted suicide and other emerging medical practices.

But Howard Brody, MD, an East Lansing, Mich., family physician who has chaired the Michigan State Medical Society's bioethics committee, is wary of the proposed measures. He said they fail to strike the proper balance between physicians' conscience rights and patients' access to care. MSMS opposes the bill in its state.

"The legislation, as we read it, has no balance," Dr. Brody said. "There's nothing in it but stating the right to object."

The proposal, for example, does not include any provisions for emergency circumstances and even would allow physicians and other health professionals to avoid discussing all the available treatment options or providing referrals on conscience grounds.

"At one extreme end, you say to the physician that if a patient wants something, you have to do it for them," Dr. Brody said. "Most of us would see that as an incredible violation. At the other extreme, you'd say not only do you not have to do it yourself, you don't have to even tell a patient about it or let them know about their options."

Edward R. Martin, director of the Americans United for Life's Center for Rights of Conscience, said he is aware that his group's sweeping approach is less popular. But "we give you the Rolls Royce, and you scale it back" if politically necessary, Martin tells anti-abortion groups and legislators around the country.

Some question emergency exception

The Rhode Island State Medical Society also opposes a bill pending in its state Legislature because, among other reasons, it doesn't provide for an emergency exception, said Kathleen Fitzgerald, MD, the group's president.

Health professionals' "right to refuse to provide a certain type of care is superseded when there's an immediate danger to a patient or they have to get someone to do it immediately for them," said Dr. Fitzgerald, a gynecologist.

Martin says that carving out exceptions for emergencies can be tricky, because they might create loopholes that could be used to force physicians and other health professionals to participate in medical services they find abhorrent.

In the case of Plan B, for example, while it can prevent a pregnancy when taken up to 72 hours after unprotected intercourse, it becomes less likely to work as the hours tick by. Many physicians say this is an emergency situation, but others disagree.

"I don't consider that an emergency," said Jane Orient, MD, executive director of the 4,000-member Assn. of American Physicians and Surgeons and a supporter of the broad conscience laws under consideration. "A mother's life is not going to end if she gets pregnant and she was careless enough to not take the proper precautions."

Some pregnancies could be life-threatening for a woman, depending on the circumstances, said Debra Stulberg, MD, a Chicago family physician who is studying the emergency treatment of ectopic pregnancies as a fellow at the University of Chicago's Pritzker School of Medicine. Dr. Stulberg added that the broader right-of-conscience laws could place physicians' values ahead of those of patients.

"When I sit down with patients to talk about their medical care, I see my job as a physician as offering a full range of medically appropriate options," Dr. Stulberg said.

"Then it's the patient's values that determine what course of action they want to take," she said. "Respecting the patient's values gets lost in these bills."

Issue is here to stay

Other than Rhode Island and Michigan, medical societies in other states considering the legislation either haven't taken a position (Missouri and Washington) or did not respond to inquiries by press time (Alabama, Tennessee, Vermont and West Virginia). South Dakota's House already voted down the measure proposed there, 35-34. The state society did not take a position.

The bill's sponsor, Rep. Don Van Etten, MD, a retired surgeon, said he would try to secure passage again next year. "My basic philosophy is that in order to get bills passed, you have to educate people that it's a good idea. And I guess I didn't do that."

The AMA has addressed conscience matters in House of Delegates policy and in ethical opinions. House policy on abortion states, "Neither physician, hospital, nor hospital personnel shall be required to perform any act violative of personally held moral principles."

Also, an AMA Council on Ethical and Judicial Affairs opinion states that a doctor may refuse to enter a physician-patient relationship when "a specific treatment sought by an individual is incompatible with the physician's personal, religious or moral beliefs."