Policy Statement-Physician Refusal to Provide Information or Treatment on the Basis of Claims of Conscience
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
FROM THE AMERICAN ACADEMY OF PEDIATRICS
Organizational Principles to Guide and Define the Child
Health Care System and/or Improve the Health of all Children
Policy Statement—Physician Refusal to Provide
Information or Treatment on the Basis of Claims
of Conscience
COMMITTEE ON BIOETHICS
KEY WORDS
abstract
conscience, conscientious objection, cooperation Health care professionals may have moral objections to particular
This document is copyrighted and is property of the American medical interventions. They may refuse to provide or cooperate in the
Academy of Pediatrics and its Board of Directors. All authors
have filed conflict of interest statements with the American provision of these interventions. Such objections are referred to as
Academy of Pediatrics. Any conflicts have been resolved through conscientious objections. Although it may be difficult to characterize or
a process approved by the Board of Directors. The American validate claims of conscience, respecting the individual physician’s
Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of
moral integrity is important. Conflicts arise when claims of conscience
this publication. impede a patient’s access to medical information or care. A physician’s
conscientious objection to certain interventions or treatments may be
constrained in some situations. Physicians have a duty to disclose to
prospective patients treatments they refuse to perform. As part of
informed consent, physicians also have a duty to inform their patients
of all relevant and legally available treatment options, including op-
tions to which they object. They have a moral obligation to refer pa-
tients to other health care professionals who are willing to provide
those services when failing to do so would cause harm to the patient, and
they have a duty to treat patients in emergencies when referral would
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2222 significantly increase the probability of mortality or serious morbidity.
doi:10.1542/peds.2009-2222 Conversely, the health care system should make reasonable accommoda-
All policy statements from the American Academy of Pediatrics tions for physicians with conscientious objections. Pediatrics 2009;124:
automatically expire 5 years after publication unless reaffirmed, 1689–1693
revised, or retired at or before that time.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
INTRODUCTION
Copyright © 2009 by the American Academy of Pediatrics
Health care professionals may morally object to particular treatments
and refuse to provide them. This practice is referred to as “conscien-
tious objection.”1–3 This statement will not address claims of con-
science on behalf of institutions. Possible examples of conscientious
objection in pediatric practice include refusals to prescribe contracep-
tion, specifically emergency contraception4; perform routine neonatal
male circumcision5; or administer vaccines developed with virus
strains or cell lines derived from voluntarily aborted human fetuses.6
Such objections may limit patients’ access to information or treatment.
Given this ethical dilemma, the legitimacy of such objections has be-
come an important issue. Legislation has been proposed both to pro-
tect health care providers’ ability to conscientiously object and to en-
sure patients’ access to health care.7
Conscience
There are morally important reasons to protect the individual’s exer-
cise of conscience even if one disagrees with the content of the consci-
PEDIATRICS Volume 124, Number 6, December 2009 1689
Downloaded from www.aappublications.org/news by guest on February 28, 2021entious belief. Conscience is closely re- controversy. Objectors have an obliga- action themselves but also to assist-
lated to integrity. Performing an action tion to explain and defend their posi- ing someone else to perform the ac-
that violates one’s conscience under- tion and may be required to demon- tion. Physicians who object to emer-
mines one’s sense of integrity and self- strate the sincerity and importance of gency contraception do not use it
respect and produces guilt, remorse, their belief.11 themselves and also refuse to pre-
or shame.8,9 Integrity is valuable, and There are, however, a number of dif- scribe it to others. They argue that
harms associated with the loss of self- ficulties in characterizing and vali- assisting others to do something they
respect should be avoided. This view of dating claims of conscience. The themselves consider immoral makes
conscience provides a justification for boundary between legitimate consci- them morally culpable. For example, a
respecting conscience independent of entious objection and unjust dis- physician whose patient makes a credi-
particular religious beliefs about con- crimination is particularly problem- ble threat against a third party would be
science or morality. Claims of con- atic. For example, the medical morally culpable if he or she refused to
science are generally negative (the profession would not tolerate a phy- warn the third party or to notify the po-
right to not perform an action) rather sician’s refusal to treat patients of a lice and the patient harmed the other in-
than positive (the right to perform an particular racial group because the dividual.
action).10 physician considered members of Whether assisting someone else to
There are potential social benefits to this group inferior. Discrimination is perform an act that you consider im-
protecting individuals’ ability to act ac- an affront to the dignity of the indi- moral is wrong depends on a number
cording to their consciences. These vidual discriminated against and of factors including intention. It would
benefits include empowering individu- may impose significant practical be wrong if you intend for the wrong to
als to think and act morally, encourag- burdens on the individual. Alterna- be committed and share the intention
ing the use of reason rather than tively, clinicians might claim that an of the person you are helping. In other
force, exemplifying and encouraging action is not intrinsically immoral cases you might cooperate in the act
tolerance, and encouraging moral ac- but only immoral when performed by but not share the other person’s inten-
tion. For example, people are more certain categories of persons. For tion, and your assistance might be ap-
likely to act morally if they are permit- example, a clinician might object to propriate. Using a bank robbery as a
ted to act on their own decisions.11 prescribing contraception to unmar- nonmedical example, the getaway
What constitutes a violation of con- ried people because the clinician be- driver shares the robber’s intention,
science may be difficult to identify or lieves it facilitates immoral sexual but the bank manager who is forced to
validate. In some situations, claims of activity. In such situations, clinicians open the vault does not. The getaway
conscientious objection may hide self- should be careful not to violate pa- driver’s actions are wrong, whereas
serving motives.12 For example, a po- tients’ privacy by asking personal those of the manager may be excus-
tential military recruit may illegiti- questions only to satisfy their own able. The moral evaluation of assisting
mately assert conscientious objection interests.13 Legally, when claims of another without sharing his or her in-
not because of moral objections to kill- conscience conflict with claims of non- tention depends on a variety of practi-
ing but because of a concern for his or discrimination in public accommoda- cal considerations including the seri-
her personal safety. Personal affilia- tions, such as hotels and restaurants, ousness of the wrong, the causal
tion with an organization that publicly nondiscrimination claims take prece- relationship between the assistance
proscribes certain actions makes it dence. Whether private physician prac- and the act, the necessity of the assis-
easier to identify true claims of con- tices should be considered public ac- tance for completing the act, and the
science. Confirmation may also be dif- commodations, and which groups of reason for providing the assistance.
ficult regarding actions that are not in- individuals should be protected against There is also the concern that cooper-
trinsically immoral but only immoral discrimination, are subjects of continu- ation may be misinterpreted as ap-
under certain conditions. Whereas ing societal debate.14 The American Acad- proval and might cause another to act
some traditions view war as intrinsi- emy of Pediatrics opposes discrimina- wrongly.16 Often, these relative deter-
cally immoral, others view the use of tion in the care of any patient or against minations do not permit clear lines to
lethal force as morally appropriate if any physician.15 be drawn between morally acceptable
certain criteria are fulfilled. Whether Evaluating claims of conscience is and immoral assistance. Questions re-
the criteria are fulfilled may depend on also difficult, because some individu- garding cooperation can become is-
empirical claims about which there is als object not only to performing an sues of conscience.
1690 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on February 28, 2021FROM THE AMERICAN ACADEMY OF PEDIATRICS
Conscientious Objection in Health late the respect that objectors them- knowingly enter a specialty with core
Care selves are seeking and are clearly activities that they are unwilling to per-
Claims regarding conscientious objec- morally wrong. It is not clear, however, form, changes in medical practice over
tion in medicine should be evaluated that refusing to cooperate is morally time should also be acknowledged.
on the health care system rather than equivalent to imposing one’s views. Some have argued that the exercise of
the individual level, because neither Physicians, except in emergencies, conscience is integral to being a pro-
the clinicians’ nor the patients’ claims have significant latitude in selecting fessional, but this claim confuses pro-
clearly trump the others’ in all situa- patients, and pharmacies may not fessional and nonprofessional com-
tions. Conflicts are often framed in stock dedicated emergency contra- mitments. Physicians generally can
terms of an individual provider and a ceptives for reasons unrelated to con- refuse to perform actions that they
single patient. Both of these individu- science. Those who refuse on the basis consider medically inappropriate. A
als have morally significant interests.17 of conscience should not be held to pediatrician may, for example, refuse
Consider a pediatrician who refuses to higher standards than those who to prescribe antibiotics for a viral re-
prescribe emergency contraception refuse treatment on the basis of other spiratory infection or perform a sur-
for a patient whose partner’s condom accepted grounds. gery that has an unacceptable mortal-
broke during intercourse. A health Constraints on claims of conscience ity rate. In contrast, conscientious
care professional might choose to can, nonetheless, be justified on the objections are typically based not on
leave medicine rather than violate his basis of health care professionals’ role medical knowledge but on moral, reli-
or her conscience. This decision could responsibilities and the power differ- gious, or political beliefs.9,11 The ability
have secondary effects not only for the ential created by licensure. Health to refuse to provide a service or treat-
professional and his or her family but care professionals fulfill a particular ment on these other bases is not part
also for patients. It might limit their societal role with associated expecta- of being a physician.
access to other services. Alternatively, tions and responsibilities. For example, One responsibility of the physician’s
the health care professional might vio- physicians’ primary focus should be on role is providing medical information,
late his or her conscience and experi- their patients’ rather than their own ben- including risks, benefits, and alterna-
ence significant guilt and shame and efit. These role expectations are based in tives, during the informed-consent
their secondary effects. Constrained part on the power differential between process. This role responsibility is sup-
access to health care may also have physicians and patients, which is the re- ported by the value of autonomy and
significant effects for patients, such as sult of physicians’ knowledge and pa- patients’ need for information to make
an unintended but possibly prevent- tients’ conditions. autonomous decisions.12 Permitting
able pregnancy. Benefits and harms to Role obligations are generally volun- physicians, on the basis of a claim of
patients should be evaluated from the tarily accepted; therefore, health care conscience, not to disclose a legally
patients’ points of view. The frequency professionals’ claims of conscientious available treatment option of which
of particular outcomes is difficult to objection may justifiably be limited. It the patient is unaware but might oth-
predict, and the type and magnitude of is unreasonable for an individual to en- erwise choose would significantly un-
these outcomes do not lend them- ter a profession or specialty with pri- dermine the practice of medicine. For
selves to weighing and balancing. mary activities that conflict with his or example, it would be unfair for a victim
Therefore, it is not possible to state in her central values.18 Individuals, how- of sexual assault who was unfamiliar
the abstract that either the health care ever, may change their moral points of with emergency contraception not to be
professional’s claim to conscientious view after having accepted a role, or informed of its existence. Acknowledging
objection or the patient’s claim to ac- the role may be redefined during the that language is not value neutral, the
cess should always prevail. course of their professional practice. information disclosed should be accu-
Some refusals constitute an imposi- The debate over physician-assisted rate, complete, easily understood, and
tion of the physician’s moral beliefs on suicide, for example, has evolved dur- focused on the patients’ decision-
the patient. Refusing to transfer a pa- ing many practicing physicians’ ca- making needs. Physicians should docu-
tient’s medical records, for example, reers.8 The boundaries of medical ment the informed-consent process in
unfairly constrains a patient’s subse- practice, both in terms of what consti- the patient’s medical record.
quent action and is morally unaccept- tutes disease and the scope of avail- As previously mentioned, clinical infor-
able.9 More egregious actions, such as able treatments, may also evolve over mation should be provided in a re-
berating or humiliating patients, vio- time. Although individuals should not spectful manner.19 Physicians can ex-
PEDIATRICS Volume 124, Number 6, December 2009 1691
Downloaded from www.aappublications.org/news by guest on February 28, 2021plain the reasons why they do not from the system of licensure.17,20 Licen- constrain patients’ access to legal
provide certain treatments or services sure requirements constrain others treatments. For example, a physician
while respecting patients’ autonomy. from providing similar services and with a conscientious objection to a
The power differential between physi- limit patients’ access. Physicians’ rela- particular procedure should avoid in-
cians and patients may, however, cre- tive monopoly on health care services tentionally displacing the only willing
ate unintended coercion. Patients and their fiduciary obligations to pa- provider of that procedure for a large
should be able to refuse to listen to tients create an obligation to treat, ir- geographic area.
physicians’ reasons. respective of conscientious objection,
in emergencies. Health care providers RECOMMENDATIONS
Similar considerations require clini-
have a duty to perform procedures 1. The American Academy of Pediat-
cians to provide prospective disclo-
within the scope of their training when rics supports a balance between
sure and referral. Physicians who, on
the patient’s health is at significant the individual physician’s moral in-
the basis of conscience, refuse to pro-
risk and an alternative health care tegrity and his or her fiduciary obli-
vide particular treatments or services
professional is unavailable.11,13 gations to patients. A physician’s
within the usual scope of practice for
their specialty have an obligation to Protection of physicians’ conscience duty to perform a procedure within
disclose this to potential patients. This and provision of legal health care ser- the scope of his or her training in-
knowledge may be important to pa- vices are both goods that the health creases as the availability of alter-
tients in selecting physicians. In some care system should protect. A variety native providers decreases and the
situations, it may be feasible to trans- of accommodations are feasible. For risk to the patient increases.
fer care. Although some clinicians ob- example, alternative modes of provid- 2. Physicians should work to ensure
ing emergency contraception include that health care– delivery systems
ject that referring makes them morally
advance prescription, pharmacist pro- enable physicians to act according
complicit,8 patients may be harmed by
vision, and over-the-counter sales.21 to their consciences and patients to
the lack of referral. Patients, particu-
Employers have important legal obli- obtain desired health care.
larly adolescents, may not know how
gations and can provide an essential
to identify a willing health care profes- 3. Physicians have a duty to prospec-
coordinating function within the
sional. Patients may also face a signif- tive patients to disclose standard
health care system. They should pro-
icant delay in obtaining a new-patient treatments and procedures that
vide reasonable accommodations,
appointment. The power differential in they refuse to provide but are nor-
such as job restructuring or modified
the physician-patient relationship is mally provided by other health care
work schedules.18 Referral services
based not only on physicians’ greater may also be created to provide re- professionals.
medical knowledge but also on their sources for patients seeking care.21 Ac- 4. Physicians have a moral obligation
greater knowledge about the health commodation efforts should recognize a to inform their patients of rele-
care system. In situations of potential wide variety of potential barriers for pa- vant alternatives as part of the
harm to patients, physicians have a tients, including education level, income, informed-consent process. Physi-
duty to refer in a timely manner. This and geography. Local variation in cir- cians should convey information
duty may be fulfilled by informing pa- cumstance makes broad policy recom- relevant to the patient’s decision-
tients about referral services such as mendations difficult.17 making in a timely manner, using
those provided by hospitals or insur- widely accepted and easily under-
Conversely, physicians have obliga-
ance companies. Physicians should stood medical terminology, and
tions to their patients. These obliga-
provide other, ongoing care while should document this process in
tions include disclosure, provision of
transferring patient care responsibili- informed consent, referral, and emer- the patient’s medical record.
ties. For example, a physician who de- gency treatment.22 Physicians have a 5. Physicians who consider certain
cides not to see unimmunized patients moral obligation to disclose their be- treatments immoral have a duty to
should continue to treat an estab- liefs to employers and to accept rea- refer patients who desire these
lished, unimmunized patient’s asthma sonable accommodations from them.18 treatments in a timely manner
until a new primary care provider can Physicians should avoid placing undue when failing to do so would harm
be established. burdens on their colleagues. Self- the patients. Such physicians must
Special obligations on the part of employed physicians should avoid also provide appropriate ongoing
health care professionals also result creating situations that inordinately care in the interim.
1692 FROM THE AMERICAN ACADEMY OF PEDIATRICS
Downloaded from www.aappublications.org/news by guest on February 28, 2021FROM THE AMERICAN ACADEMY OF PEDIATRICS
6. Physicians should work to ensure COMMITTEE ON BIOETHICS, Marcia Levetown, MD – American Board of
that employers make reasonable 2008 –2009 Pediatrics
Douglas S. Diekema, MD, MPH, Chairperson Anne D. Lyerly, MD, MA – American College of
accommodations for employees’ Obstetricians and Gynecologists
Mary Fallat, MD, Chairperson-Appoint
conscientiously held views and that *Armand H. Matheny Antommaria, MD, PhD Ellen Tsai, MD, MHSc – Canadian Paediatric
responsibilities are equitably dis- Ian R. Holzman, MD Society
tributed among colleagues. Aviva L. Katz, MD
Steven R. Leuthner, MD, MA CONSULTANTS
7. In emergencies, when referral Lainie F. Ross, MD, PhD Jessica Wilen Berg, MPH, JD
would significantly increase the Sally A. Webb, MD
probability of mortality or serious LIAISONS STAFF
morbidity, physicians have a moral Philip L. Baese, MD – American Academy of Alison Baker, MS
obligation to provide treatment. Child and Adolescent Psychiatry *Lead author
REFERENCES
1. American College of Obstetricians and Gy- rived from aborted human fetuses. Natl 15. American Academy of Pediatrics, Commit-
necologists. ACOG committee opinion No. Cathol Bioeth Q. 2006;6(3):541–537 tee on Pediatric Workforce. Nondiscrimina-
385: the limits of conscientious refusal in 7. National Conference of State Legislatures. tion in pediatric health care. Pediatrics.
reproductive medicine. Obstet Gynecol. Pharmacist Conscience Clauses: Laws and 2001;108(5):1215
2007;110(5):1203–1208 Legislation. Denver, CO: National Confer- 16. Griese ON. Catholic Identity in Health Care:
2. American Medical Association, Council on ence of State Legislatures; 2007 Principles and Practice. Braintree, MA: The
Ethical and Judicial Affairs. CEJA Report 6-A- 8. Wicclair MR. Conscientious objection in Pope John Center; 1987
07: Physician Objection to Treatment and medicine. Bioethics. 2000;14(3):205–227 17. Fenton E, Lomasky L. Dispensing with
Individual Patient Discrimination. Chicago, liberty: conscientious refusal and the
9. Wicclair MR. Pharmacies, pharmacists, and
IL: American Medical Association; 2007. “morning-after pill.” J Med Philos. 2005;
conscientious objection. Kennedy Inst Eth-
Available at: www.ama-assn.org/ama1/ 30(6):579 –592
ics J. 2006;16(3):225–250
pub/upload/mm/369/ceja㛭6a07.pdf. Ac- 18. White M. Conscience clauses for pharma-
cessed December 2, 2008 10. Allen WL, Brushwood DB. Pharmaceutically
cists: the struggle to balance conscience
assisted death and the pharmacist’s right
3. General Medical Council. Personal Beliefs rights with the rights of patients and institu-
of conscience. J Pharm Law. 1996;5(1):1–18 tions. Wis L Rev. 2005;(6):1611–1648
and Medical Practice. London, England:
General Medical Council; 2008. Available at: 11. LaFollette E, LaFollette H. Private con- 19. Chervenak FA, McCullough LB. Clinical
www.gmc-uk.org/guidance/ethical㛭guidance/ science, public acts. J Med Ethics. 2007; guides to preventing ethical conflicts be-
personal㛭beliefs/personal㛭beliefs.asp. Ac- 33(5):249 –254 tween pregnant women and their physi-
cessed December 2, 2008 12. Dresser R. Professionals, conformity, and cians. Am J Obstet Gynecol. 1990;162(2):
4. Stein R. Pharmacists’ rights at front of new conscience. Hastings Cent Rep. 2005;35(6): 303–307
debate; because of beliefs, some refuse to 9 –10 20. Charo RA. The celestial fire of conscience:
fill birth control prescriptions. Washington 13. Cantor J, Baum K. The limits of conscien- refusing to deliver medical care. N Engl
Post. 2005:A1, A10 tious objection: may pharmacists refuse to J Med. 2005;352(24):2471–2473
5. British Medical Association. The law and fill prescriptions for emergency contracep- 21. American Academy of Pediatrics, Commit-
ethics of male circumcision: guidance for tion? N Engl J Med. 2004;351(19):2008 –2012 tee on Adolescence. Emergency contracep-
doctors. J Med Ethics. 2004;30(3):259 –263 14. Appel JM. May doctors refuse infertility tion. Pediatrics. 2005;116(4):1026 –1035
6. Pontifical Academy for Life. Moral reflec- treatments to gay patients? Hastings Cent 22. Asch A. Two cheers for conscience excep-
tions on vaccines prepared from cells de- Rep. 2006;36(4):20 –21 tions. Hastings Cent Rep. 2006;36(6):11–12
PEDIATRICS Volume 124, Number 6, December 2009 1693
Downloaded from www.aappublications.org/news by guest on February 28, 2021Physician Refusal to Provide Information or Treatment on the Basis of Claims of
Conscience
Committee on Bioethics
Pediatrics 2009;124;1689
DOI: 10.1542/peds.2009-2222
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/124/6/1689
References This article cites 15 articles, 4 of which you can access for free at:
http://pediatrics.aappublications.org/content/124/6/1689#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Current Policy
http://www.aappublications.org/cgi/collection/current_policy
Committee on Bioethics
http://www.aappublications.org/cgi/collection/committee_on_bioethi
cs
Ethics/Bioethics
http://www.aappublications.org/cgi/collection/ethics:bioethics_sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
http://www.aappublications.org/site/misc/Permissions.xhtml
Reprints Information about ordering reprints can be found online:
http://www.aappublications.org/site/misc/reprints.xhtml
Downloaded from www.aappublications.org/news by guest on February 28, 2021Physician Refusal to Provide Information or Treatment on the Basis of Claims of
Conscience
Committee on Bioethics
Pediatrics 2009;124;1689
DOI: 10.1542/peds.2009-2222
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/124/6/1689
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2009
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
Downloaded from www.aappublications.org/news by guest on February 28, 2021You can also read
