Doctors at religious hospitals face ethical conflicts over care
■ Most physicians in a recent survey said they would refer their patients elsewhere for barred services, but 4% would violate hospital policy to provide care.
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One in five primary care physicians working in religiously affiliated health care organizations has experienced a conflict over faith-based patient care policies, according to a new study in the Journal of General Internal Medicine.
The findings, based on a nationwide survey of 446 family physicians and internists, appear to be the first to document how frequently doctors disagree with institutional policies in areas such as reproductive and end-of-life care, said Debra B. Stulberg, MD, the study's lead author.
"It's an issue that patients and we, as physicians, should be aware of," said Dr. Stulberg, instructor in the Dept. of Family Medicine at the University of Chicago Pritzker School of Medicine.
Most of the physicians reporting conflicts worked in Catholic hospitals, which account for 12.5% of all U.S. community-based hospitals and 15.5% of hospital admissions, according to the Catholic Health Assn. of the United States.
Catholic hospitals are required to follow the U.S. Conference of Catholic Bishops' religious directives on medical care that bar contraception, abortion and sterilization and, in many instances, rule out ending artificial hydration and nutrition.
When conflicts arise, 86% of surveyed physicians said they would encourage patients to seek the recommended care at another hospital. Ten percent said they would offer an alternative treatment that could be delivered at the religious hospital, and 4% endorsed violating the hospital's policy to provide the care.
Referring patients to another hospital may not be in the patient's best interests, said Dr. Stulberg, particularly for time-sensitive interventions such as emergency contraception. Referrals also can impede access to care for patients who live in underserved rural areas or lack access to transportation, she said.
"Telling the patient they have to go someplace else can, at the very least, introduce a delay in getting the care," Dr. Stulberg said. "That concerns me."
The study, published online April 6, highlights how religious policies can interfere with physicians' medical judgment, said Lois Uttley, director of the MergerWatch Project. The New York City-based group opposes health care organization mergers between Catholic and nonsectarian hospitals that result in reduced access to reproductive care services.
"This is a very urgent problem and has been understudied. Until now, the balance of research and public policy in this country has focused on physicians and hospitals that want to refuse to provide certain health services because of their religious or moral beliefs," Uttley said. "What we haven't seen given proper attention is the ethical dilemma facing physicians who want to provide services because their patients need the services but who are unable to do so because of institutional religious restrictions."
David Stevens, MD, said the study does not raise serious concerns about access to care.
"Physicians approach this issue like they approach a lot of issues," said Dr. Stevens, CEO of the 15,000-member Christian Medical & Dental Assns. "They have a patient with a certain problem and they look for the best place to care for that problem ... This is much ado about very little."
The real problem, he said, is that physicians who oppose practices that conflict with their religious faith face increasing pressure to violate their deeply held beliefs. The outgoing Bush administration addressed that concern, issuing a December 2008 rule authorizing the Dept. of Health and Human Services to deny federal funds to health care organizations found discriminating against health professionals who object to providing abortion-related services.
The Obama administration pledged in March 2009 to rescind the rule, but has yet to take action on the issue. The White House referred an American Medical News query on the matter to HHS, which did not respond by this article's deadline.
The American Medical Association has policy that opposes requiring doctors to perform procedures that violate their moral principles.
Uttley said that, with health system reform enacted, the Obama administration should take action and rescind the Bush conscience rule.