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Right of Conscience

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Rob Stein
Washington Post Staff Writer
Monday, July 17, 2006; 11:00 AM

Around the United States, health workers and patients are clashing when providers balk at giving care that they feel violates their beliefs, sparking an intense, complex, and often bitter debate over religious freedom vs. patients' rights.

For example, some anesthesiologists refuse to assist in sterilization procedures, respiratory therapists sometimes object to removing ventilators from terminally ill patients, and gynecologists around the country have declined to prescribe birth control pills.

Legal and political battles have followed. Patients are suing and filing complaints after being spurned. Workers are charging religious discrimination after being disciplined or fired. Congress and more than a dozen states are considering new laws to compel workers to provide care -- or, conversely, to shield them from punishment.

Washington Post staff writer Rob Stein was online Monday, July 17 at 11 a.m. ET to discuss this debate.

A transcript follows .

Read the stories here:

A Medical Crisis of Conscience

Seeking Care, and Refused

For Some, There Is No Choice

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Washington, D.C.: How wide-spread a problem is this issue? Are these cases of medical professionals refusing care or facing employment issues still relatively rare? Have there been any surveys of medical professionals to see how the larger community feels about these issues?

Rob Stein: Unfortunately there is no good data on how frequently this occurs. A few surveys have been done though. One, of nurses, for example found a significant proportion said they had been in situations where they felt their personal beliefs were challenged.

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Bethesda, Md.: Could you provide a little more background on the Chicago EMT story? I'm curious about the status of the woman who was awaiting transport. If her health status was serious enough to require an ambulance, then it sounds as if the EMT put the needs of the fetus above those of the woman. Could you please comment?

Rob Stein: There isn't much information available about the patient. It was listed as an 'elective abortion,' implying that it was not an emergency situation.

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Vienna, Va.: This country, for good reason, does not recognize a "right" to anything other that medically necessary treatment.

Do you see the movement towards forcing medical personnel to provide unnecessary medical treatment as a greater fight for some type of inalienable right to premium health care? (I do.)

Rob Stein: That's an interesting point. Some of the experts I interviewed for these stories pointed out that part of what's going on in this debate is the changing nature of the health care provider-patient relationship as patients have become more assertive.

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Washington, D.C.: Has this 'right of conscience' been practiced as widely in the past or is this a relatively recent phenomenon given the current political climate?

Rob Stein: It has been an issue for a long time. After the 1972 Roe vs Wade decision, for example, states began passing 'conscience' laws that specifically protected doctors and nurses who did not want to do the procedures. Nearly every state now has one of those on the books. It also came up when Oregon legalized physician-assisted suicide. That law too allows health care workers to opt out.

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Silver Spring, Md.: I have HMO coverage so my choices of health providers is not always that wide. If I want something that someone decides goes against their ethical principles is my HMO obligated to provide me with that service if it is legal within my state?

Rob Stein: There are some states that are considering new laws that would allow health care plans to NOT cover certain things.But if the care is currently covered by your plan it should continue to do so.

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Arlington, Va.: As a student planning on attending medical school next fall, I find it appalling that medical professionals place their own moral agenda ahead of what is best for their patient. Religious objection to me is not a compelling reason for refusing service to someone. Why is the AMA and some states allowing this to happen?

Rob Stein: The AMA hasn't directly addressed this issue directly, although its ethics guidelines do specify that physicians have an obligation to put patients concerns first. States are considering laws on both sides.

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Maryland: It seems to me that prescribing and talking about birth control is a pretty important part of a gynecologists' job. I would imagine that any gyn. who declined to do this would quickly find himself without patients! I know I would leave, after I gave him a piece of my mind. The problem is that some women in more rural parts of the country may not have much choice in gynecologist.

Why did these people become gynecologists if they have a fundamental problem with such a large part of the job?

Rob Stein: Those with objections say they don't have any problem with most aspects of their jobs they have no problem doing. It's just certain aspects -- abortions, sterilizations, birth control -- where the conflicts arise.

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Arlington, Va.: Great series. About choice though, many patients who have HMOs don't really have a choice of physicians. You have to pick a primary care and then get referrals. Did you come across anyone in your reporting that had this problem? Couldn't get a prescription, but couldn't go to another doc either?

Rob Stein: That was part of the problem with the Guadalupe Benitez case -- the gay woman in California who was turned away by her fertility clinic. That clinic was the only one covered by her plan. She ended up going to another clinic outside her plan.

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Washington, D.C.: In addition to individual refusals, isn't it the case that institutions are being granted a right to refuse as well? For example, aren't Catholic hospitals permitted to refuse to provide services related to abortion, contraception, and end-of-life care? How does this affect patients' right to care?

Rob Stein: Yes, this is a very big issue. Catholic hospitals are do not perform abortions or sterilization procedures or dispense the morning-after pill. Prochoice advocates have become especially concerned about this when Catholic hospital chains take over other hospitals in certain areas. In part in response to this, there is legislation pending in Congress that would require all hospitals to provide emergency contraception to rape victims.

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Annapolis, Md.: Thanks for these eye-opening articles. This is scary stuff. We rightly expect "professionals" in whatever field to perform their duties in a "professional" manner, perhaps more so when they are licensed by the government. If there are duties that conflict with your religious beliefs, DON'T go into that field. The most repugnant quote for me was the following:

Pharmacist Gene Herr was fired by a drugstore in Denton, Tex., in 2004 after refusing to fill a rape victim's prescription for the morning-after pill. "This was the worst-case scenario," Herr said. "This was the hardest decision I ever made. The heinousness of a rape is a horrible thing. But I don't think you should punish a child for the sins of the father."

What about the victim? What kind of deity would punish the victim twice, for the rest of her life? And where does it end?

My question is, do you see any concerted effort at fundamentalist colleges to recruit and fill the ranks of pharmacists, etc., for the express purpose of exerting their own beliefs?

Rob Stein: Haven't heard about anything like that happening...

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Orlando, Fla.: Our right to religious freedom is absolute. What is not absolute, however, is any "right" to be a physician or a pharmacist or to engage in any licensed profession when one's religious beliefs interfere with his or her ability to practice that profession. My question is, what under our laws, constitution, or traditions permits a licensed professional to retain his or her license to practice in the face of any inability to discharge the duties of that profession faithfully, whether the impediment is religious, physical, or some other factor?

Rob Stein: That's, of course, a big part of this debate. Those defending the religious workers cite the First Amendment, Civil Rights legislation, and 'conscience clause' laws enacted by the states.

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Pittsburgh, Pa.: About gynecologists and birth control: I realize there were space limitations, but I was surprised to see no mention of the fact that a large number of women receive prescriptions for the pill for reasons having nothing to do with birth control. Instead, the pill can be used to regulate painful or irregular menstrual cycles. For me personally, this has been a huge help in holding a job; I used to be knocked flat for two days every month, and with the aid of the pill, I'm not.

I'm horrified that people specializing in women's health would deny me this relief based on the fact that they disagree with -another- purpose the pill is often used for. Their dogma interferes with doing their job (i.e. keeping women healthy), and they should find another line of work.

Rob Stein: That's a good point. One of the stories that I heard in reporting this story but didn't have room for involved a woman who was trying to renew her birth control prescription for exactly that use, but was turned away.

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Rockville, Md.: I'm torn on this issue. Part of me says "if you cannot/will not do all aspects of the job, pick another profession" but part says "in elective procedures, why can't they go elsewhere?"

The ambulance driver had a job. That job is to transport patients. Where they were going is all she needed to know. My feeling is by letting her know the procedure, that was a violation of doctor/patient confidentiality.

As for pharmacists, the pharmacy should make a decision of which drugs to stock and which not to. When hiring a pharmacist, the job requirement is to fill every legal prescription presented. If a pharmacist cannot/will not fill every prescription, they shouldn't be hired. If they agree to fill all but then don't, they should be fired for breaching the contract.

Anesthesiologists (and doctors in general) should be able to choose to not participate in whichever procedures they don't want to UNLESS it is non-elective (i.e. an emergency).

Maybe I'm skewed since I've always lived my life in areas that have multiple doctors and pharmacies (different stores - not just different branches) all within a 5 mile radius. Is it really that different in small towns?

Rob Stein: That's the big concern. In some rural areas there is often only one drug store, clinic or hospital nearby. Patients can always drive elsewhere, but if they are poor that can be a big boundary...

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Rockville, Md.: Do the doctors you interviewed openly state their beliefs to new patients? It seems like if these doctors have such strong beliefs about which procedures they will or will not perform, they should be up front with their patients so that their patient is not left without service in a time of crisis.

Rob Stein: Many of the doctors and other health care workers I interviewed do take pains to make sure they make their beliefs clear to their employers, co-workers and prospective patients. But not all do. And sometimes problems arise when new patients come in who don't realize this about the doctor. Other times problems crop up when workers get drafted to fill in and do jobs they don't usually do -- like a nurse who usually only works in pediatrics gets drafted to work in the ER.

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Rockville, Md.: On a financial level, healthcare level, there's a push to make the doc-patient relationship more of a client-provider relationship. As a customer, I have a right to ask if certain tests are necessary, to seek out treatments, ask the doctor about new drugs and treatments. On the other hand, we often don't have these choices. For example, many medical situations, time is of the essence, like the morning after pill. I'm willing to pay for it, but can't get it in time... so we're not really customers in the economic sense.

Rob Stein: Good point. And that's where a lot of folks draw the line -- in emergencies. In those situations most agree the patient has to come first. The question sometimes becomes: What is an emergency?

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Idaho Fall, Idaho: What do organizations like the AMA have to say about refusing to refer someone elsewhere for a treatment the provider feels he can't, in conscience, provide, and the withholding of information on other options available that the provider disapproves of?

Rob Stein: The AMA says providers have an obligation to fully inform patients of all their options and refer them elsewhere if they cannot provide care.

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Washington, D.C.: This brings up a slippery slope question for me: How far are those in support of conscience clauses willing to let it go? Can Christian Scientist doctors refuse to give blood transfusions? What about a pharmacist who refuses to fill a scrip for anti-depressants because he believes psychology is a symptom of secular society's selfish nature and that mental illness doesn't exist (as I was taught in church as a child in the 1980s)? I know Parkinson's patients who have been berated while getting a scrip filled by people who think that their medication comes from stem cell research?

Where does it end?

Rob Stein: That is a concern that many have expressed about this issue. And there is a concern about how this is going to play out in the future as medical advances continue to come into conflict with people's beliefs. Embryonic stem cells is the obvious example. If it starts to produce treatments as many hope, will some doctors and other providers refuse to off them?

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Rochester, Minn.: In December of 1995 my husband was in the hospice part of a general hospital in Mesa Arizona. He was being given morphine to curb his suffering, cancer. He needed another dose of morphine, a suppository, but the nurse refused suggesting he needed to be more aware at this time, a few days before his death. I replied that his suffering needed to be eased. She then responded "Christ suffered". I agreed but added that, "Bad men caused his (Christ's) suffering". The nurse just walked away. A shift change was to happen in about half an hour and another nurse caught my eye. I was aware of his unspoken message to just wait for the shift change. I did, and the morphine was given. At the time I didn't realize I should have lodged a complaint with the hospital. My own functioning was very impaired due to the situation. Apart from that incident the hospice care was very good, for my husband and helpful for my son and myself, particularly the doctor, other nurses, and aides. Later there was follow up at intervals also to see how we were doing.

The way I see it is that people in extreme situations, my own for example and many others in different situations, are not in a position to carry on a discussion presenting cogent arguments for why the requested procedure should be implemented. They are not usually in an emotional situation to fight back. I wasn't.

The situation the person is in is being used against them, by a person in power, in my case a nurse, who was going against hospice principles to ease a patient's suffering. In my case the nurse was using her (mistaken) understanding of Christianity to justify her refusal to ease suffering for my husband in his last few days. In this was she was an active party to his continued suffering.

Eleanor

Rob Stein: Thank you for sharing your story. I had heard stories like this happening in situations like yours...

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Male Sterilization Issue...: I remember when I went for counsel with my doctor about getting a vasectomy, that my doctor wasn't happy or thrilled about it. She basically asked several questions. I didn't mind the questions but they weren't "health" related, more "moral and what if" questions that could be construed as trying to change my mind about having the procedure. I sensed she had objections about me getting the procedure but she relented. I got it done. Are those types of questions "normal" within healthcare or are they "out of line"? Although it was subtle, I did feel like my doctor didn't want me to get a vasectomy and was trying to convince me not to do it.

Rob Stein: That's an interesting scenario. As you might have noticed, most of the cases tend to involve women -- primarily because objections tend to center on reproductive health issues. But I did speak to some doctors who refused, for example, to fill prescriptions for Viagra for unmarried men.

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Southern Maryland: Excellent, but scary article.When did the concept of discrimination go awry?

When did a professional's religious beliefs become more important than a state's licensing board? All of the professionals described in the article are governed by state regulations (and were trained/educated to meet standards); how can they 'cry' discrimination on the basis of religion if they knew beforehand what the position entailed?

Rob Stein: Sometimes the problems arise when new developments come along that create conflicts for workers that didn't exist when they decided to go into their profession. For some pharmacists, for example, the "morning-after" pill was not an issue when they decided to become pharmacists.

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Washington, D.C.: What makes it permissible for these 'Christian' individuals to impose their beliefs on others? If such religions discriminated more blatantly on the grounds of race, gender, etc then it would be illegal. What then protects this specific set of beliefs from prosecution?

These individuals are professionals, and as such, have professional obligations that they are beholden too. Police, public defenders, and others often have to provide service for individuals whose beliefs/actions they personally object to. But because of the moral equality of individuals, they are required to do so. What makes these medical providers exempt from such obligations?

How conveniently they forget, in their haste to judge, God's own words - "Let he who is without sin cast the first stone."

Rob Stein: Those who would defend the right to refuse would argue that other professions do have that right. Lawyers, for example, can opt not to accept a client.

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Washington, D.C.: Did you happen to check into insurance coverage? I noticed your reply, above:

Rob Stein: That was part of the problem with the Guadalupe Benitez case -- the gay woman in California who was turned away by her fertility clinic. That clinic was the only one covered by her plan. She ended up going to another clinic outside her plan.

If an insurer covers a treatment, and the only covered provider refuses to provdie the treatment, is the insurer obliged to find another way to ensure its clients have access to that treatment?

Rob Stein: Usually those kinds of issues are regulated by state laws, which means it would vary state by state.

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Warrenton, Va.: In your research, did anyone for a right to refuse care give any explanation of where such a right would terminate? It seems to me from the articles I've read on the topic that advocates for a right to refuse care don't establish any clear limitations. For instance, would a particularly bigoted doctor be able to refuse care to an interracial couple through childbirth, because he felt morally wrong about their relationship?

I simply cannot see how such a decision would be remotely ethical, yet it is what people are advocating for when they call for a right to refuse care. Perhaps if they are unable to do their jobs, they should find a new one?

Rob Stein: Most draw the line at refusals that are clear examples of outright discrimination or in situations where the health of the patient would be endangered.

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Minneapolis, Minn.: Great series. I have a real problem with doctors, nurses, EMT workers, pharmacists, etc. exerting their personal beliefs when treating patients. Religious freedom is absolutely necessary in our country, but I believe when you take an the oath to practice medicine, you are putting those beliefs aside.

I am looking at this issue in the big picture. If these professionals can exert their personal influence, why can't other professionals? For example, I used to teach. What if I wanted to hit a child? In the Bible it says, "spare the rod, spoil the child." (Not that I agree with that, but I think you get my point.) What if I decided that I no longer wanted to teach elementary science because it "conflicted with my religious beliefs?" That wouldn't fly because teaching science is my job. It should be the same thing for these people. However, when women and reproductive issues come into play, suddenly EVERYONE has something to say. I feel like this could be a real slippery slope.

Rob Stein: Yes, that's definitely one of the issues that this debate raises...

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Rob Stein: Thanks everyone for a great hour. Lots and lots of very smart, passionate and provocative questions. This is obviously an issue that arouses a lot of strong feelings, and is unlikely to go away any time soon.

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