New ACOG position on abortion refusal drawing fire
■ Anti-abortion doctors say it obliges them to become morally complicit, but the position's supporters say personal views should not trump patients' access to care.
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A recent American College of Obstetricians and Gynecologists' position statement outlining the limits of conscientious refusal in reproductive medicine is drawing fire from physicians who oppose abortion.
The ACOG Committee on Ethics opinion says doctors whose personal beliefs may require them to "deviate from standard practices" such as providing abortion, sterilization or contraceptives should:
- Give patients prior notice of their moral commitments and provide accurate and unbiased information about reproductive services.
- Refer patients in a timely manner to another doctor who can provide the requested service.
- Provide medically indicated services in an emergency when referral is impossible or might affect a patient's physical or emotional health.
- Practice close to physicians who will provide legal services or ensure that referral processes are in place so that patient access is not impeded.
The opinion, published in November 2007, comes in response to heated debate over some pharmacists' refusal to fill patient prescriptions for Plan B, known as the morning-after pill. The Food and Drug Administration in September 2006 approved Plan B for over-the-counter status, but the debate over the right to refuse certain procedures or medication has not disappeared.
In its opinion, ACOG cites other cases of impeded reproductive access it finds disturbing, such as a California doctor's refusal to provide artificial insemination to a lesbian couple and a Nebraska hospital's refusal to perform an abortion for a 19-year-old with a life-threatening pulmonary embolism.
"Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled," ACOG says in its statement. The organization had not granted AMNews interview requests by press time.
David Stevens, MD, CEO of the Christian Medical & Dental Assns., said ACOG's position "minimizes the whole concept of the right of conscience and elevates the patient's autonomy as the trump card. If the patient wants it, the doctor has the obligation to provide it."
The ACOG position ignores "the issue of moral complicity," Dr. Stevens said. "For those physicians who see abortion as taking the life of a human being, that extends to even making a referral."
Dr. Stevens agrees with ACOG that physicians are obligated to provide medically accurate information about abortion and other reproductive services but that a referral is a kind of endorsement of another physician -- one that doctors who oppose abortion cannot make in good conscience.
Sigrid Fry-Revere, PhD, a bioethicist at the libertarian Cato Institute in Washington, D.C., agreed.
"Physicians shouldn't be required to inform themselves about who does the type of medicine they believe is immoral," she said. But, she added, hospitals and office-based physicians should prominently notify patients about policies limiting access to reproductive services.
Lee P. Shulman, MD, said the ACOG position "sets an appropriate standard for clinicians" in dealing with how to balance the physicians' conscience rights and patients' right to access care.
"I have no problem with a physician who opposes abortion, but I do have a problem with a physician who has those views take over the entire relationship," Dr. Shulman, professor of obstetrics and gynecology at Northwestern University's Feinberg School of Medicine and chair of the Assn. of Reproductive Health Professionals' board of trustees. "The patient may not share those views but is then a prisoner of that clinician on whether to even talk about this issue."
Two states, Illinois and Mississippi, have comprehensive laws allowing health care professionals, payers or organizations to object conscientiously to participating in any medical service.
Forty-five states let doctors refuse to provide abortions.
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."