The World Health Organization defines health as the general well-being of physical, psychological and social life. Medical care is a strictly regulated service, and doctors, nurses, pharmacists, and other care providers have to show a level of competence to be licensed to practice in the states. Therefore when we need medical care, we expect a certain standard of care to be met. In medicine, standard of care is a minimum level of care to maximize the chance of a positive health outcome.
Modern standards of care are set by different disciplines and include evidence-based practice, patient-centered care, and prevention. We expect all people concerned in our care to have our well-being as their ultimate concern. We expect our treatment to be endorsed by scientists and clinicians as effective.
We also expect to receive full information about our diagnosis, about the recommended treatment, about the prognosis with and without treatment, about the risks involved in the treatment, and about alternative treatments available. Only with this information can we make informed choices about our care, We also expect appropriate referrals when needed.
We also expect information on how to prevent the spread of disease, and to maintain our health.
But what if our doctor, or the hospital we go to, base their practice on something other than the best health outcome? What if we unknowingly go to a hospital that refuses to allow its doctors to tell patients of all their options for treatment, or where they can go for treatment that doctor does not provide? What if the we have no way of knowing that this doctor or clinic refuses to do what the evidence indicates would be helpful?
This is increasingly the case where refusal clauses protect those who refuse adequate treatment and information to patients. A recent study by the National Health Law Program looked at medical systems that included 650 hospitals nationwide regarding their practice and implementation of refusal (or conscience) clauses, and found evidence of all the questions posed in the previous paragraph.
Refusal clauses are usually presented as the conscience of a provider and the conscience of a patient. This framing leaves out one very important factor: is the patient’s health negatively affected by the refusal of treatment or the lack of information about all possible options?
Many of these matters of conscience concern reproductive health, and disproportionately affect women.
There was the recent case of Sister Margaret McBride, who was an administrator at a Catholic hospital in Phoenix, Arizona. She was faced with a decision involving a woman admitted critically ill with pulmonary hypertension, who was also 11 weeks pregnant. With almost no chance of surviving if she remained pregnant, the woman, her family, and her doctors all favored an abortion. Calling on a Church ruling that allows life-saving treatment for a woman even if it would harm her fetus, Sister McBride approved the operation. When the Bishop learned of this, he said it meant automatic excommunication.
A more common example is managed care organizations run by Catholic agencies, which don’t counsel women about birth control or refer them to places where they can receive counseling. This also happens with pharmacists who refuse to dispense emergency contraception, or emergency rooms that do not include emergency contraception in rape kits. It is only recently that military facilities were required to do so.
An example that affects both women and men, as well as society as a whole, is the refusal to instruct HIV-AIDS patients that condoms can prevent spreading the disease.
Refusal may come on an individual level, as with the pharmacist, on an institutional level, as with the case of Sister McBride, or politically through laws that disregard medical evidence but are influenced by religious forces, which legislate such protections for providers refusing to provide or refer for often very necessary services. This has also shown itself in the issue of teaching how to perform abortions in the training of obstetricians and gynecologists; such training is part of training programs.
The reframing of the question to include the question of whether refusal causes harm to patients is important and necessary. The first rule of the medical profession is to do no harm. Ethical standards in professional organizations put the patient’s well-being over the conscience of the provider, who must provide the needed care if no alternative is possible. Passing laws to exempt providers from the results of their actions is a way around the ethical guidelines for doctors, nurses, and other health professionals, and needs to be reconsidered.