A frequent commenter on the conscience issue has raised a lot of questions on an recent post. He seems somewhat frustrated that I don’t understand his point. What I think he doesn’t realize is that I do understand his point all too well—he is just wrong. Here is an example:
You also still haven’t cleared up that little inconsistency regarding the matter of whether or not there is a professional obligation to provide elective services. Or is it just physicians, but not pharmacists or other healthcare professionals, who have rights of conscience?
OK, I’ll clarify it for you. It’s not that doc’s have a “right of conscience”, it’s that they cannot be unreasonably coerced to provide services. This does not mean that a physician or other provider is never required to provide a service. In other words, if some random person walks in the door of my office, I don’t have to see them. If I am an ER doc and someone walks in the door with a life-threatening condition, I DO NOT have the right to refuse them care, whatever my beliefs. I am required by law to stabilize them and if I am unwilling to continue to care for them, transfer them appropriately (the transfer doesn’t happen much in practice). Of course, no one can hold a gun to my head. If I refuse to serve the patient, and no one else is available to do it, I have committed a highly unethical act. If someone else is available, I can be fired for failing at my job. I am welcome to follow my conscience all I want, but as with conscientious objectors throughout history, I have to be willing to accept the consequences of my actions.
This whole idea of “elective services” is a straw man invented by the commenter. He has also frequently used the term “medically indicated”. The health professions each have their own responsibilities. There exist in medicine standards of care, which guide the way we take care of patients. We provide preventative services, and we treat diseases. We follow the science-based guidelines of our professions. Not everything we do is a directly life-saving intervention. For example, if someone has a backache, I can choose to tell the patient to take a motrin, or I can tell them to suck it up. Neither recommendation will change the course of their illness—the back will heal in a few weeks with either approach. One of these may in fact provide more comfort, so it is the better choice in most instances. Was it “medically indicated”? Was it “elective”?
But those who argue for conscience clauses don’t usually want to deprive people of motrin; it is almost about women’s health—contraceptives, Plan B, abortion. All these things are “medically indicated” in that when used properly, they are part of the standard of care. If I prescribe an oral contraceptive to a male, that is most definitely NOT medically indicated.
Now, some folks would like to dodge this whole ethical issue by simply making any medications that they aren’t comfortable with available over-the-counter. This way, a woman can simply walk into the drug store and buy contraceptives without any interference. This is a terrible idea. Dodging ethical questions rarely solves them, it simply creates more layers of problems. If we were, for example, to make OCPs over-the-counter so that pharmacists wouldn’t have to be bothered dispensing them, we would be depriving women of the crucial counseling and advice that they can get from their physician. OCPs are not all the same; patients are not all the same. Further, the patina of discrimination raises the bar on justification—if you are going to act in a way that disproportionately affects a particular group negatively, your actions deserve special scrutiny.
When encountering an ethical problem in health care, you have to look it right in the face—dodging it only creates more problems. The most important needs in health care are those of the patient. That isn’t to say that providers don’t have needs, simply that their needs are of a lower priority than those of patients. And if you wish to exercise your rights of conscience at the expense of your patients, you can do so—but not without consequence.