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Molecules to Medicine: “Conscience” Clauses versus Refusal: An Historical Perspective

The views expressed are those of the author and are not necessarily those of Scientific American.


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The struggle between conscience and refusal, or individual rights vs. that of the community good, goes far back, and is not limited to reproductive choices. It also forms the foundation of civil rights rulings—prohibiting discrimination and segregation, and discrimination based on race or religion. Unfortunately, there are still ongoing battles regarding discrimination based on sexual orientation.

In Benitez, Doctors at the North Coast Women’s Care Medical Group denied Ms Benitez infertility treatment because she is a lesbian, “claiming that their personal conservative Christian beliefs gave them a right to withhold care that they routinely provide to heterosexual patients.” The California Supreme Court issued a “unanimous, landmark decision that lesbians are entitled to the same treatment as other patients and that constitutional protections for religious liberty do not excuse unlawful discrimination.”

“Conscience,” or personal beliefs, was also used to deny care to HIV/AIDS patients. I started practice well before HIV-AIDS was recognized, when little was known about its transmission. I clearly recall the struggles both of patients and of health care workers who wanted to refuse to provide care to AIDs patients—either because of their religious beliefs or because of their own fears of becoming ill. Despite these concerns, it was demanded that health care workers care for all, and put the patients’ needs first.

We have always had societal expectations for the behavior of physicians and the presumption that they would put patients needs first. For example, British apothecary William Boghurst wrote of those who fled London during the Great Plague in 1666, “Every man that undertakes to be of a profession or takes upon him any office must take all parts of it, the good and the evil, the pleasure and the pain, the profit and the inconvenience altogether and not pick and choose; for ministers must preach, captains must fight, physicians attend upon the sick…. ”

The AMA code of 1847 similarly asserted the physician’s duty to treat, “And when pestilence prevails, it is their duty to face the danger and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives.” This was later altered to give greater weight to physicians, who shall, “except in emergencies, be free to choose whom to serve.” Especially since the HIV/AIDS era began, the consensus has been that along with whatever benefits and status being a physician brings, is also a unique social responsibility.

Most recently, the issues of conscience and responsibility came to the forefront during the SARS and Ebola epidemics, and during the aftermath of disasters such as Hurricane Katrina. In a thoughtful post, “Virulent Epidemics and Scope of Healthcare Workers’ Duty of Care,” Daniel Sokol provides a more nuanced exploration of competing duties—to patients, but also to their families and other responsibilities. He thus argues that the duty to patient needs must be put in the context of the other responsibilities and especially of the level of risk.

In each of these historical cases and discussions regarding the duty to treat, the only exceptions have related to health care worker’s personal risk, usually due to epidemics. Nowhere has there been sanctioned denials of care—and even emergency medical care for (miscarrying) women—because it offended a provider’s beliefs.

An illuminating comparison can be made between women’s healthcare issues and other issues that some in our society find morally or religiously objectionable. In an excellent post, “Not all Choice is Free,” Louis A. Ruprecht appropriately concludes, “The question that should be asked is why the US Catholic Bishops are exerting so much energy and money and time on the matter of contraception, with no similarly public cries of outrage against the death penalty, state-sponsored torture, or the two preemptive wars in which the U.S. has involved itself for fully a decade. Clearly there is a lot more to this debate than the First Amendment. It has to do with one of the most powerful patriarchal religious organizations in the world—be sure to recall that the bishops are all men, every last one of them—placing itself squarely in opposition to women’s sexual equality and autonomy.”

In 1985, a North Carolina resident withheld a penny from his taxes to protest the death penalty and execution of Velma Barfield. He claimed “a religious exemption from paying for state services to which he was opposed on moral and religious grounds. The state’s answer was simple in the spring of 1985: you don’t get to pick and choose the services you pay for, regardless of the reason.”

Catholic hospitals provide 20-30% of the hospital care in the United States. Religious health systems received more than $45 billion in public, taxpayer-supported, funds, including Medicare and Medicaid funding. The Catholic Health Association, for example, also receives huge tax breaks as a “non-profit, charitable” organization. Thus, religiously-affiliated health systems have an enormous influence on health care, especially in rural areas, where they are often the sole provider.

Particularly in light of the 1985 court’s decision in the death penalty tax case—“you don’t get to pick and choose the services you pay for, regardless of the reason,”—and given the huge amount of public monies they receive, should religious health care institutions be allowed to impose their beliefs on others? Should their beliefs trump the medical needs of patients who are seriously ill and may not have anywhere else to go for care? There is simply no precedent for such a demand based on personal beliefs.

Refusal clauses deny our patients the care that they need. They are not benign clauses, euphemistically referred to as “conscience” clauses. They are, instead, unconscionable clauses, shirking the professional responsibility to put our patients first.

Previously in this series:

Molecules to Medicine: Clinical Trials for Beginners
Molecules to Medicine: From Test-Tube to Medicine Chest
Lilly’s Shocker, or the Post-Marketing Blues
Molecules to Medicine: Pharma Trumps HIPAA?
Molecules to Medicine: Should pepper spray be put on (clinical) trial?
Molecules to Medicine: FDA at a Crossroads—a Tough Place to Be
Molecules to Medicine: Plan B: The Tradition of Politics at the FDA

Judy Stone About the Author: Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.

The views expressed are those of the author and are not necessarily those of Scientific American.






Comments 5 Comments

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  1. 1. carmen2u 11:41 am 03/20/2012

    Another compelling essay, Dr. Stone, as usual. I agree that the medical oaths doctors have accepted are universal to their profession, without carve-outs. Once exceptions are made, we have introduced a two-tiered system of care. A doctor to some is no doctor at all.

    The latest episode of reproductive care denial reveals the core power struggle women are battling with men: deciding who controls their bodies. My generation assumed we had the right to govern our bodies, a right which prior feminists fought to win. Now, here we are 30 years later regurgitating this matter all over again. It’s time for an equal rights amendment to put all antiquated views of women to rest.

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  2. 2. Angel56 11:53 am 03/20/2012

    I fully agree.”Conscience” for a doctor should mean the Hippocratic oath- help those in neeed, without discrimination. anything other is INcoscience!

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  3. 3. brynnscott 5:34 pm 03/20/2012

    Thank you, thoughtfully and beautifully written.

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  4. 4. DXM26 11:24 pm 03/25/2012

    “I clearly recall the struggles both of patients and of health care workers who wanted to refuse to provide care to AIDs patients—either because of their religious beliefs or because of their own fears of becoming ill.”

    I don’t know what the relevance is of medical ethics relating to risk of contracting a disease from a patient. As to religious belief, there is no Church teaching that would sanction refusal to treat a person because he is a homosexual. None. The Catholic Church teaches that persons with homosexual inclination “must be accepted with respect, compassion, and sensitivity. Every sign of unjust discrimination in their regard should be avoided.” (Catechism, section 2358.) Anyone who claims that this is not the teaching of the Church is misinformed. Mother Teresa and many, many other Christians have ministered to AIDS patients. As to risk of contracting diseases, numerous saints have risked their lives to minister to those suffering from contagious diseases (for example, St. Francis and Fr. Damien both ministered to lepers (and Fr. Damien died of leprosy as a result)).

    “The question that should be asked is why the US Catholic Bishops are exerting so much energy and money and time on the matter of contraception, with no similarly public cries of outrage against the death penalty, state-sponsored torture, or the two preemptive wars in which the U.S. has involved itself for fully a decade.”

    The issue is not contraception but, rather, the HHS mandate, which is an existential threat to the Church’s ministry to the sick. The modern hospital as we know it today derives historically from the Church’s mission to provide for the poor, the sick, widows and strangers. Cf. Council of Nicea (325 A.D.). The Church cannot carry out this mission if as a condition of doing so she is required to repudiate her own principles. The death penalty, state-sponsored torture and the two (?) pre-emptive wars present no analogous threat to the Church’s mission.

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  5. 5. BobNSF 12:45 pm 03/26/2012

    “The Catholic Church teaches that persons with homosexual inclination “must be accepted with respect, compassion, and sensitivity. Every sign of unjust discrimination in their regard should be avoided.” (Catechism, section 2358.) Anyone who claims that this is not the teaching of the Church is misinformed.”

    And anyone who believes that is delusional. The Church has led the prosecution of gay people for well over 1500 YEARS. This recent revision to the Catechism is a sham. Note the careful word choice. No “unjust” discrimination. Turns out, around the world, that ANY anti-discrimination laws are “just” if the Church says so — and they do — because to treat us as equals would, in time, damage “the family”. The Vatican won’t even back calls for decriminalization.

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