Doctors and the "conscience clause"

[Beorning]

Here's something that's being a point of debate right now in my country: the doctors' "conscience clause".

What is it about? Basically, we have pretty strict laws regarding abortions - it's permitted only in a few cases, like when the pregnancy threatens the mother's health or (I think) is the result of a rape. Yes, it's a strict law (at least in comparison to the rest of Europe) - but, in theory, woman *should* be able to get an abortion done in these few cases.

But... it's not that simple. A pregnant woman might go to a hospital, get a gynecologist assigned to her, ask for abortion... but the doctor is allowed to decline. They are allowed to call for the "conscience clause": declare that abortion goes against their moral beliefs and that they aren't going to do so.

I was wondering: is it similar in other countries? Or is the conscience clause something atypical?

As to why that subject is currently hot back here: it's because of situation from one hospital that got just described by our media. A woman was eligible for abortion and wanted it done, but she didn't get it. Why? Because the hospital's chief of medicine was anti-abortion and decided that abortions won't be happening in his hospital at all. All in the name of the conscience clause. Note that we're talking about a public, tax-funded hospital here...

[Iniquitous]

I cannot speak for every state - or every city in the every state - but I know there are some OB/GYN doctors around here who refuse to do abortions. And there is nothing that says they HAVE to provide them. Now as far as hospitals? That I do not know about.

[Deamonbane]

Hmmm unless the woman is actually in danger in which having an abortion would mean better chances of her survival... or in that area (Health-related abortions in general) I don't see why a doctor shouldn't be able to decline on performing an abortion on moral or religious grounds. Unless the health of the mother depends on it, a doctor shouldn't be forced into doing something that he disagrees with. Of course, it should be a choice made by the doctor, not by the chief of Medicine of the hospital on behalf of all the doctors in the hospital.

[meikle]

To be clear, the "conscience clause" is the part that says that, if I own a pharmacy, I'm not allowed to fire my pharmacist for refusing to fill prescriptions for birth control.

I think that's pretty ridiculous; these are laws meant to make it more difficult to receive these services and nothing else -- they exist so that healthcare providers can't say, "Do your job or I will find someone who will."

The conscience clause isn't what allows a doctor, pharmacist, whatever, to say, "No, I'm not going to do that" -- nobody can force them to do anything -- it's what says that you can't fire them for refusing to provide service.

[ThePrince]

In the United States a doctor can invoke the "conscience clause" but they can not with hold information on where she can receive an abortion or falsify the risk of getting an abortion. So as long as a woman is able to receive the medical attention she request, I'am fine with the "conscience clause".

Today we seeing this more in the technical sense, with the passing of the Affordable Health Care Act and almost all businesses are required to provide a form of health care. Some business owners do not want to provide in some manner contraceptives. It is currently being played out in Sebelius v. Hobby Lobby Stores, Inc. Hopefully the ruling will be "No, obey the law or forgo the tax credits" or else they will upset massive precedences.

[Beorning]

In theory, I'm okay with the conscience clause, too... The problem is when it goes too far. Like in the recent scandal I mentioned - when there was, apparently, a pressure at all of the gynecologists in the hospital not to conduct abortions. According to the news I've heard about this case, the doctors were simply afraid to conduct abortions, as they could get fired by their anti-abortion chief of medicine.

Also, there's the problem that some of the doctors want the conscience clause to go even further. They say that they should also not be required to inform their patients where else they can get abortions. Not to mention, there are apparently situations when the doctors not only decline to conduct abortions, but they actively cause their patients to be tied in the red tape, so that they wouldn't be able to get abortions in time...

Finally, it's not only about abortions. The doctors want to be allowed not to prescribe contraceptives or prenatal child examinations...

[Iniquitous]

Ok I am confused on that last sentence. They do not want perform abortions - okay, that is their right.  But they do not want to prescribe contraceptives to stop unwanted pregnancies?  Did they just time travel from the middle ages? And they do not want to provide prenatal care? Why are they OB doctors then? That is part of the primary job of an OB doctor ffs.

[Beorning]

Well, as far as I observed, the conscience clause is often called upon by doctors subscribing to Catholic worldview. And according to the Catholic church, both abortions *and* contraception are sinful. Remember that the CC doesn't even allow condoms...

As for refusing the prenatal examinations: the same doctors seem to be afraid that their patients will ask for abortions, if they learn that their children have Down syndrome or something like that. So, again: they don't want to prescribe these examinations.

[Pumpkin Seeds]

I am not really sure the government of any nation or the citizenry of that nation should feel comfortable forcing people to go against their ethical codes and values.  Most people and jobs have a form of “conscious clause” in their work places.  Bartenders may refuse to serve a pregnant woman drinks, veterinarians may refuse to declaw cats and medical professionals may refuse to perform certain procedures.  A doctor, a nurse and even nursing assistants all have the right to refuse to give care to a patient unless this is a life threatening emergency.  Of those three, only the doctor is legally obligated to give care (at least in the United States).  Now each profession faces consequences to their actions, but they are legally protected if they felt that caring for the patient was against some form of morale practice.  I have seen nurses refuse to care for HIV patients, for people they felt were “ungodly” and for patients they simply could not handle personally.  Do I think this is right, not really but at the same time you do not want someone caring for you that does not feel they can give an unbiased and objective service.

Doctors are in a tough spot on some of these issues.  While we may comfortably shake our heads at their refusal to perform an abortion, if that physician truly believes they are killing a child then what right do we have to make them do this?  Do we have the right to make them do, what they believe is the equivalent of putting a gun to a pregnant woman’s stomach? 

[Beorning]

True, but what about the other side of the coin? Imagine you're a woman with a health-threatening pregnancy. You know you are eligible for abortion, you go to a doctor... and the doctor goes "Nah! Nah! I believe that abortion is a sin, so you won't be getting any!". Then, you ask the doctor where you should go to... and he refuses to tell you, either... Is this OK?

[Oniya]

As a woman who has gone through pregnancy (thankfully with no issues, but this is a hypothetical), I would be going through the phone book (or almighty Google) from top to bottom if necessary, if my health was in danger and I ran into a doctor like that.  I don't think it's 'okay' for a doctor to knowingly endanger someone's health, but I wouldn't be sitting back and just taking 'no' for an answer.

[Callie Del Noire]

Do I have an issue with a doctor following his/her conscience? No. So long as they are up front, honest and openly disclose it. Hiding behind it without disclosure and using it as a shield from controversial issues. That I would have a problem with.

Doctors, by dint of their massive ability to impact a persons life should follow and develop their ethics and conscience. That 'an do no harm' bit, it can be pretty heavy. A

[DemonessOfDeathValley]

Personally, I don't agree with *all* abortions. In my opinion, if an individual doctor (not someone acting on 'behalf') makes the decision not to perform an abortion for whatever reason, they should then inform the patient of a place where they can receive this service. Not tie them up with red tape, embellish hazards or any other ploy to delay the procedure until it would be too late.

I'm not against a doctor declining based on their personal beliefs. I'm against a doctor, or any person for that matter, imposing their personal beliefs on another. Especially when those beliefs might endanger someone's health.

[Rogue]

I honestly hold the same thoughts on this that I do most other Religious based issues in the US:

If you are a member of a private practice or religious affiliation, you are perfectly within your rights to deny me whatever you feel like you should deny me. If you think I should die due to an injury because I'm in a homosexual relationship (or that you should pray me through it), that still makes you a shitty person, but I will not deny you your religious beliefs. (A bit extreme but bare with me)

However, if you are part of a public health care facility funded by the government in any way shape form or fashion, or an ER which I think should all have a portion funded by the government: You best remember that you are a government employee and separate your religion from this train of thought. A government employee should understand that religion has nothing to do with your job and provide me the healthcare I need to the best of their abilities, be that an abortion or anything else.

If a person is going to get an abortion for any other reason, I can't say anything on it besides there are other things at stake besides physical health. It's why rape victims don't get questioned when they want an abortion. An abortion for a rape victim is more for their mental health. After all, who a person's parents are do not affect whether a fetus is considered alive or not. A fetus is either considered a person or not, regardless of parents. Therefore it must be for the mother's mental health. This would also apply for the 16 year old who didn't realize she wasn't ready or the 21 year old who didn't realize that antibiotics can fuck with your birthcontrol. Having a child is an amazing mental strain, and it should be up to the parent if they want to have that mental stress or not.  Being forced to go through with a pregnancy you didn't want/don't want is like being told your body is no longer yours which can be traumatic. Not even mentioning the financial strains. Emotional/mental health are things. Choosing abortion is already hard enough for most people, a public provider should be able to provide it without religious affiliations getting in the way.

As for pharmacists: the public sector is allowed to sell what they want. If, for instance, CVS suddenly decided they didn't want to sell birth control, whatever they want. However, if a pharmacist is employed at another store that does sell birth control, they should do their job or I'm taking it to management. Pharmacists know what they're signing up for when they apply at a store. If I have to deal with awkward conversations because I'm an employee and can't politely escape, you have to do your job too.

[Oniya]

It's why rape victims don't get questioned when they want an abortion.

Shouldn't get questioned.  As much as I would hope that it was different, I know that there are organizations who try to make contact with women who are 'pregnant and scared' (and any one of your examples could fall into that category) and try to talk them out of abortions if they've decided that they want one.

[Rogue]

Shouldn't get questioned.  As much as I would hope that it was different, I know that there are organizations who try to make contact with women who are 'pregnant and scared' (and any one of your examples could fall into that category) and try to talk them out of abortions if they've decided that they want one.

I mean by actual medical professionals. Unfortunately, people are assholes and will try to shove their beliefs down other's throats. Even if they'd just gone through something traumatic.

Edit: SOME people are assholes. >.> Realized afterwards. My bad.

[Pumpkin Seeds]

Endangerment of life does change the playing field some.  A physician cannot so easily dismiss an abortion case due to their conscious when that case involves the life of the mother.  Failing to perform a lifesaving procedure does come with serious civil and criminal ramifications.  Granted they are not always enforced, but the threat is there.  Under those circumstances the abortion does become a medical necessity and declining to do so is paramount to murder at the worst and negligence at the least.  If the physician is not capable of doing the procedure then he must arrange for timely transport of the patient to a facility that will provide the care.  This holds true at least in the United States.

Now if a doctor I was seeing refused to perform an abortion due to his personal beliefs, I would have a problem with the physician’s beliefs.  I would not have a problem with their refusal to do so.  Once more, medical necessity does change things because then the doctor is making a conscious choice to kill us both due to his beliefs.  No mother, no baby afterall.

As for the bit about doctors being government employees, I do think we need to be careful before telling doctors to follow government policy over their own ethics.  Medicine has not always been the good guy in the past.

For reference though, if someone is having difficulty with a hospital then they should also ask to speak with the ethics board for the hospital.  While they may not force the doctor to perform the procedure (in fact I doubt seriously that would even come up) they will be able to assist in finding someone that does not have such a problem.

[Rogue]

As for the bit about doctors being government employees, I do think we need to be careful before telling doctors to follow government policy over their own ethics.  Medicine has not always been the good guy in the past.

I wasn't necessarily meaning government policy. Doctors know more than politicians about their fields after all. However, the basic principle of separation of church and state should still apply as far as denying someone a medical procedure is concerned.

[Pumpkin Seeds]

Separation of church and state does not apply when someone is asked to commit what they believe is murder.  If we are discussing a non-life threatening abortion, then someone’s enjoyment of one night is not worth forcing someone to violate their ethical codes and perform a procedure they view as murder.  Without harm to the mother present, abortion is an entirely elective surgery.

[kylie]

          I am no expert, but I believe part of the problem is some of these decisions are being made in places where there are not many affordable or appropriately equipped facilities within easy travel distance. 

          Also, in some cases part of the calculation may be that one cannot afford to deal with a child -- and that often even overlaps with poorer communities where one will be blamed for having a child and not taking personal responsibility for raising it. 

         Even if you think that is rather silly and it would be preferable to put an infant up for adoption, you can see how that amounts to giving some groups preference in who gets access to and control over what kinds of children.  It might become a sort of either social engineering (more financially able white families would get their pick of duly surrendered black babies from poorer communities, to put it bluntly), or perhaps even eugenics (if you say ideally they wouldn't have had the babies if they can't afford them) , all riding on the back of "family values" claims.

         So it is not merely about who gets to say who shouldn't be having sex without forced responsibility for undesired childbirth ('all this for someone's night of pleasure' as Pumpkin put it).  I find it difficult to deny individual doctors the option to refuse simply to do a procedure, but when it comes to withholding information about something that involves so much immediate work for the mother and huge long-term social questions like these...  If people have nowhere to go in their region with their finances as they are, and they are not given maximum choices when they ask a professional, then the odds of many other very unpleasant outcomes all increase.
     

[Pumpkin Seeds]

A woman can easily avail herself of multiple avenues of discovery for an abortion.  There are hospital social workers; there is hospital administration, Planned Parenthood and even Google.  At some point ignorance does become less of a reason and more of an excuse.  There are many tools at someone’s disposal to discover the location and times that this procedure can be done.  Logistics of location is a valid problem, however.  Still an OBGYN physician located in a rural community cannot immediately be expected to perform every procedure required by that community simply because they are there.  Oddly enough people would have an easier time swallowing that the OBGYN does not have the equipment for an abortion procedure because the procedure isn’t profitable than the doctor is refusing to do so because of their ethics.

Logistics is more a problem for local governments, especially with their measures to close down abortion clinics as of late.  A physician has no responsibility to violate their ethical practices due to logistics.  As for the selling of birth control and Plan B, there is still the problem that a woman has made a choice to pursue sexual relations even if these medications are not available.  Rape aside, a couple that engages in sexual activity without protection has no one to blame for this pregnancy but themselves.  Forcing the physician to carry out a procedure they view as murder is a poor remedy and so is blaming a pharmacist for the same.  There does have to be responsibility taken by those engaged in the activity after all.

[Rogue]

Separation of church and state does not apply when someone is asked to commit what they believe is murder.  If we are discussing a non-life threatening abortion, then someone’s enjoyment of one night is not worth forcing someone to violate their ethical codes and perform a procedure they view as murder.  Without harm to the mother present, abortion is an entirely elective surgery.

I believe I addressed that in my original post but I'll rewrite it here:

In a private sector, do as you wish. I could care less if you deny me services for me being a lesbian for religious regions as long as I can deny you services for being a jackass. If you choose to work in a public sector: be prepared to do an abortion.

I disagree whole heartily that abortions are completely elective. There's other forms of health besides physical and I believe that those should be addressed. The ability to handle the emotional and financial stress of a child because the condom broke, you were 16 and didn't realize you weren't ready (heaven forbid you were emotionally pressured into it because we don't consider that rape in our society), you didn't realize antibiotics mess with birth control, and any number of these reasons. And regardless of if you say "you should put it up for adoption!" I would just like to point to these statistics regarding adoption. There are way to many people already in the system! Please stop encouraging people to do this to children! Yes, if you're lucky, you'll meet someone and start working on adoption right away, but that doesn't always happen. Don't damn someone to live like that. Okay?

If you believe that a bundle of cells that haven't even formed a fully functioning human (which is when all legal abortions are made) is a living being, don't work in the public sector. It's really that easy with me.

Pumpkin, there is an entire state where women currently can't realistically get abortions (*cough* TEXAS *cough*) and it's not financially viable to make someone travel to another state for one. Ignorance might not be an excuse for someone who lives in a city like mine where there's a planned parenthood within half an hours drive from me. However, maybe those avenues that you listed should be better known. Because they're not. Not enough is known about abortion to the average adult until they have to go get one themselves (if they go that route). And let's face it they're already having to go through the emotional ramification of deciding to end what some consider a life and is at the very least the potential for life. Hell, knowledge about women's health in general as well as different birth control options aren't as well spread as they need to be. I would like to point out that some people still believe that women pee out their vaginas. That the most talked about forms of birth control are the Pill and penile condoms. And woman centered birth control is very expensive in comparison to condoms that are handed out like candy.

I also do not like that you assumed that the sperm donor would be a part of this decision. Because A) the sperm donor in not regardless of if they are a couple. It's the pregnant one's decision because it's their body and ultimately their responsibility regardless of the sperm donor's opinion. they don't have to inflate like a balloon, they don't get a choice. B) sometimes it's a one night stand and the birth control fucked up. Sperm donor doesn't necessarily even get to know about the fetus because any number of reasons.

There are also horror stories of people poking holes in condoms to try to get their SO pregnant. ((I've seen evidence of it happening before with the one getting pregnant wanting to get pregnant and I know there are people on both sides of that coin)) Should that person be responsible because they thought they were having sex with a working condom? I don't think so.

((Of course there are people who treat abortions like they would a breast implant or any such elective surgery, but most people realize how dangerous having surgery is and would weight between the pro's and con's.))

[Rogue]

I know I'm double posting but I figured this might be relevant and feel like it warrants a read either way. :) Thank you.

http://americanprogress.org/issues/religion/news/2013/08/08/71893/scarlet-letters-getting-the-history-of-abortion-and-contraception-right/

[Pumpkin Seeds]

I would like to point out first that this is not a debate about abortion.  We are discussing whether a physician may refuse to perform an abortion or any other procedure due to their own ethical standards and their own judgment.  These are not uneducated and untrained people, but are very smart and learned people that have formulated their own ethical guidelines and judgment on this issue.  A physician specializing in OBGYN and able to perform this sort of procedure understands better than any of us the formulation of cells and what happens during conception and pregnancy.  If that person still holds onto an opinion that this is life, that they do not agree with abortion or perhaps that they simply do not believe people should be able to “opt” out of a mistake then that is their choice.  The objections to performing an abortion are not simply religious ones, believe it or not. 

Women do not have a right to have an abortion.  They have the right to make a choice and seek an abortion, but they do not have an explicit right to have this procedure performed.  Pregnancy, all things being equal, is not a debilitating condition.  An uneventful pregnancy does not equal loss of limb, life or permanent injury that is outside the natural realm.  While you may disagree that abortion is not medically necessary, the fact remains that an abortion is not medically necessary.  Stress, financial burden and mental anguish are not part of the criteria to justify a procedure as medically necessary or to make the procedure a requirement.  The patient is pregnant and is making their desire known to have an abortion; they are electing to have an abortion.  This makes the procedure an elective one, pretty much by definition.   So there is simply no basis for a woman to force another person to commit what they feel is murder.  There is no ethical ground, legal standing or even a basis for someone to demand that another person do what they feel is wrong.

As for public versus private sector, I do think there is some misunderstanding about how physicians operate in the scope of things.  For starters there are hospitals that are subsidized by the government in order to provide some form of healthcare to the citizens.  The hospital publically funded or not, will still make an attempt to collect payments owed by the people seeking treatment at the facility.  Almost every hospital does this and so at the end of the day the hospital is still seeking compensation from insurance companies.  Non-profit and for profit hospitals also draw largely from the government in the form of Medicaid and Medicare, which make up the largest portion of payments that a hospital receives.  So the line is very much blurred between the two.  The main difference between them is that the government gives grants and money to keep the hospital afloat, while other hospitals draw largely from their patient load.  Keep in mind most hospitals operate in the red.

Most doctors are actually independent contractors to the hospital.  This means that the hospital does not actually employ the doctor directly, but rather contracts out to the physician.  Now certain hospitals will work to keep a doctor with their hospital so that they can bill to their patients.  For instance the hospital I work for has one of the best general surgeons in the region that also performs a rare procedure called a “whipple.”  The hospital does everything possible to retain this surgeon at their facility, but the surgeon is free to leave for another hospital at any time.  Surgeons and doctors typically operate their own clinics outside the hospital.  This is where things such as admitting privileges come into play in the most recent attacks on abortion clinics.  Admitting privileges mean that the doctor may admit their patient to that hospital directly, rather than going through another physician.  A physician may have admitting privileges to several hospitals and even in different regions of the state depending on their clinics and their patient populations.  Therefore, the doctor refusing to do the operation is likely not a government employee but simply works at the public hospital.

Typically the physicians at a hospital are residents, which are doctors that are training to perform this specialty.  A resident must have an attending surgeon or what is typically called “staff” to oversee their actions during an operation.  If the surgeon states they will not oversee the surgery, then the resident cannot perform the procedure.

So hopefully this shows that the public vs private thing doesn’t quite work in the American system of medicine.

As for lack of knowledge about sex, contraception and foul play in a relationship there is simply the ugly truth that life is not fair.  The physician and in truth the medical system is not responsible for making life any more fair.  This state of affairs does not mean doctors must then abandon their principles and ethics in order to perform an elective surgery.  Governments are shutting down abortion clinics due to loopholes and technicalities that I sincerely hope are overturned, but that does not justify forcing someone to go against their principles. 

[Sabby]

We are discussing whether a physician may refuse to perform an abortion or any other procedure due to their own ethical standards and their own judgment.  These are not uneducated and untrained people, but are very smart and learned people that have formulated their own ethical guidelines and judgment on this issue.

They're also doctors. They have a job to do.