Reply turned post, conscience clauses can be OK style

I am starting to grow weary of being the contrary voice. I duck out of many confrontations, believe it or not. But, sometimes I still speak up.

More than once, a liberal, pro-choice site has taken a stance against conscience clauses in general. Although I am a pretty vocal pro-choice commenter in the interwebs, I find myself defending conscience clauses in these conversations.

This time, I replied on a Feminists for Choice post asking if conscience clauses were ethical:

I am a medical student and a member of Medical Students for Choice.

I strongly believe in conscience clauses and plan on refusing to perform certain procedures and to dispense certain medications when I am a physician. I think every physician follows her conscience, and am afraid anti-choice activists are using this important part of medical ethics to refuse to provide services that are in the best interest of the patient.

I plan on refusing to perform unnecessary procedures that are requested all the time as an ob/gyn. I will not perform any genital mutilation, male or female. This includes any routine newborn male circumcision, or elective vaginoplasties. This of course does not extend to any medically indicated procedures, which would be in the patient’s best interest.

I will refuse to do labor inductions because a mother is sick of being pregnant or because I am going on vacation. I will refuse to do non medically indicated cesarean section because a mother is afraid of the birth process or wants to have her baby on a certain date, or because I want to get home in time to have dinner with my family on a day I am being paid to be on call.

I think practitioners that are truly ethical do not use conscience clauses as an excuse to deny medical treatments to their patients or clients because of some idea that premarital sex is immoral. It is easy to find work in an area that does not involve refusing to provide necessary medical care. Most of these people who are refusing reproductive health care want to make an issue out of their refusal to control women’s sexual autonomy, not to support their own ethics, and it’s a shame.

There are two students in my medical school class who have stated they will refuse to prescribe birth control. Both identify as Catholic. One was more than happy to take handfuls of condoms our club was passing out for when he has sex with strippers (I wish I was kidding). He said he is using them for disease prevention, not birth control, so he is not a hypocrite.

I hope he goes into radiology, or urology.

The other is a Jesuit priest. He is planning on going into psychiatry, so most likely won’t be in a position to be a birth control prescriber often. He is also honest and out in regards to his homosexuality, and is an activist to change the Catholic position on homosexuality. So, he thinks some rules are meant to be changed.

The point of these two stories is to say, ethics mean different things to different people. Physicians and other health care practitioners are too diverse a group to force into one group of practices. However, we can encourage responsible application of conscience clauses and try to make sure essential health care does not get refused in the process.

10 Comments

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10 responses to “Reply turned post, conscience clauses can be OK style

  1. Well put comment. You’ve made me rethink my feeling about conscience clauses in allowing ethical health care providers not being forced to provide services/health care that is not in the best interest of the patient. Although this type of clause has been used most specifically in the use of women’s health reproductive services, you bring up an excellent point that providers should also be given the right to refuse services they deem as not in the best medical interest of their patient.

  2. ninjanurse

    I think a pharmacist refusing to dispense the morning after pill is kind of like me making a huge donation to charity using your money. There’s too much ‘conscience’ that consists of professionals making a moral stand when the patient takes all the consequences.
    On the other hand, I don’t see any good in trying to get doctors and nurses to provide abortions if they have an objection to doing it. How to draw the line I don’t know.

    • MomTFH

      It is a tough question. I don’t think forcing physicians or practitioners to perform abortions is the answer. However, I think it can definitely be part of a job description, and once hired for that position with knowledge of that requirement, the person should either perform their job or be disciplined / fired.

      This isn’t too difficult. Most major hospitals do not perform elective terminations – these almost exclusively happen in an outpatient setting in clinics. I think very, very few health care practitioners have a problem participating in a procedure that is necessary for the mother’s health, e.g. removing an ectopic pregnancy. I know there are a few.

      If someone is an extremist enough to not want to prescribe or take part in any birth control related health care, there are plenty of Catholic hospitals out there, and tons of options in private practice and in other specialties. I don’t think it is too much to ask someone who is adamantly opposed to birth control to avoid an occupation in which it would come up.

      In fact, a self described “pro-life” attending ob/gyn physician at a major public hospital and ob/gyn residency said she regretted putting herself in the position of being the only attending one night when there was a potential ectopic rupture, and she put the patient in jeopardy by not being trained on how to handle it (by choice!), and had to call in another attending from home. She shared this story with our ob/gyn interest group.

      I cannot imagine having an ob/gyn attending in charge in a major city’s only public hospital (and only ob/gyn residency in a six hour driving radius) who was unwilling and apparently unable to handle such a common life threatening obstetric emergency. She didn’t make it clear what has been done since then to prevent this from happening again. I am hoping she got trained that night, and in the future will not only take care of the patient in this sort of situation, but will adequately train the four years worth of residents she is supervising.

      I know my views on circumcision are somewhat outside of the medical norm in my community. I will definitely investigate my ability to refuse to perform what is an elective, non medically indicated procedure before there is a patient in front of me. I will discuss it with my higher ups, and see what options I have to refer out routine newborn circumcision, which I think is still the domain of ob/gyn residents (why? I don’t know).

      I am going to have a harder time with refusing to participate in non medically indicated inductions and cesareans in my residency training. I am probably going to have to struggle with that on a case by case basis. I can’t imagine any residency program would be too thrilled with me if I tried a blanket refusal on anything I saw as more risky than advantageous to the patient, considering how common those types of interventions occur in obstetrics. I am sure any promises to “keep my mouth shut” would be laughable, considering my personality, but I also understand my future role as a resident, and will have to balance my crusading against the medicalization of obstetrics and my desire to make it through a residency program.

      I think I will most likely refuse to perform any episiotomies, however. We’ll have to see how that goes.

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  4. Here is the thing. You don’t get credit for what you think you are going to do. I am not speaking to you specifically but med students as a whole. I have been in the position of refusing to do X, Y or Z procedure. Not an easy place to be. There have been times when I was the only one who spoke up. Even the Doctors just sat there and waited. In fact it is one of the hardest things I have had to do as a professional. I find instead of just digging my heels in and saying NO. It is often better to ask them why. Why do they want to induce this woman at 37weeks. Then discuss the literature. If it is not evidence based, you have a good argument and they know it.

  5. re: circumcision- I do know a few obstetricians and nurse midwives who chose not to perform them. They explain this to their patients if it’s brought up. I believe the obstetricians learned how to do them in residency, but once on their own chose not to. They refer to their colleagues if parents chose to have it done on their newborn.

    Nurse midwives are in a unique position to never do them as it’s not in our core competencies. So the nurse midwives who do them choose to do them. Which I have always found to be against the nature of the philosophy of midwifery.

    I think pinky has a good suggestion for approaching the issue of not wanted to perform procedures that are not evidence based or medically necessary. Does obstetrics residency have core competency that includes circumcision?

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