White Coat Underground

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.


  1. #1 Anon1
    March 18, 2009

    Just saying that making oral contraceptives over the counter would deprive women of “crucial counseling and advice” isn’t very convincing. If women wanted such counseling, they’d still be free to visit their doctor and ask for advice, as they are now. They’d just have the option, as the women of Japan and Spain do now, of making their decision about contraceptives privately. That’s a terrible idea?

  2. #2 PalMD
    March 18, 2009

    I did anticipate that question…

    I still think that for OCPs, it’s best to have the advice of a physician…there are a lot of choices and a lot of patient variables.

    Also, if avail OTC, there will be changes in the health care system to match this—visits for OCPs won’t be covered, the drugs won’t be covered, etc.

    I don’t think that OCPs meet the safety threshold for OTC use.

  3. #3 bob koepp
    March 18, 2009

    Ok, I’ll pick it up and go from here.

    The “little inconsistency” can’t be evaded so easily. Pal, you’re on record saying inconsistent things about whether or not there’s a professionally-grounded obligation to provide elective services. In addition to various interventions geared to control reproduction, there are also things like “cosmetic” amputations and, if you were in Washington or Oregon, assisted suicide. Now traditionally, the medcial profession has claimed that providers are not obligated to make elective services of this sort available, though it’s acceptable for them to do so if they so choose. Do you reject that tradition, or do you just want to exclude non-physicians from enjoying such rights of conscience?

    I certainly haven’t invented the notion of ‘elective services’, nor have I simply imagined that it serves as a contrast to ‘medcially indicated’ services. You can’t get away with “making it up as you go”, since anybody who wants to know the truth of the matter can turn to any number of medical sources that use these terms in precisely the way I have.

    I’m not trying to “dodge” any ethical issue(s) by advocating for true “over the counter” availability of Plan B. The FDA’s scientific advisors think it should be OTC. Are they wrong, or is it just in this particular case that you want to ignore their fact-based recommendations?

    I agree that ethical problems, in healthcare as elsewhere, should be faced directly. Again, it’s not me that’s being dodgy about ethical issues… There’s a huge one that you have thus far refused to address. We live in a society that purports to endorse the liberal enlightenment value of “freedom of conscience.” Unless we’re going back to square one of political theory, we don’t ask for justification of this freedom — we assume it as part of the context of discussion. What needs to be justified is limitations on this freedom. And there’s also a fairly well-articulated account of what sorts of limitations can be justified. If you can make your case while facing up (directly) to these matters of ethics, have at it. But don’t just wave your arms, stamp your feet and throw mud at anybody who says something that runs counter to your prejudices. And that’s what they are Pal. Unless you can give a reasoned account of the positions you take, they’re nothing but prejudice.

  4. #4 anonymouse
    March 18, 2009

    I really like how the Secular Coalition for America puts it:

    “Health care workers (whether they are doctors, pharmacists, technicians, or emergency medical technicians) are employed in the field of medicine, not spirituality. They have the right to consider their own religious beliefs in determining what medical decisions they make for their own care, but their personal religion should never infringe on the right of a patient to seek products or procedures that they have a legal right to obtain.”

    If you are not willing to prescribe or dispense certain medications or administer certain treatments because you consider them immoral, then you ought to choose a profession other than health care (or choose a specialty in which you will not have to confront the issue-podiatrists, I’d wager, seldom find themselves being asked to prescribe oral contraceptives). When the medications and treatments are beneficial and safe for the individual patient, and legal, you must not place your moral objections above the right of patients to access those medications and treatments. You may choose for yourself. You may not choose for everyone else.

  5. #5 Courtney
    March 18, 2009

    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.

    Pardon me if I’m wrong, but isn’t a condom contraception? I don’t hear you advocating for condoms to be sold only by pharmacists. You’re perfectly fine with reliable male contraception being sold OTC. What you’re really advocating for is for the primary method of reliable women’s contraception to be sold by pharmacists, thus limiting their availability.

    The only ethical question I see you confronting is whether or not women should have the right to use contraception without a physician’s supervision.

  6. #6 PalMD
    March 18, 2009

    I was unclear.

    I do think that certain contraceptives should indeed require a physician’s precription, for example, IUDs…

    Reasonable people can disagree about OCPs being OTC…i happen to think it’s not a great idea, as they are not entirely benign in certain patients.

  7. #7 Whitecoat Tales
    March 18, 2009

    Courtney –
    While I see the comparison between OCP and condoms as birthcontrol, and the ethical question you raise concerning availability, they aren’t exactly the same.
    Different kinds of condoms still all work the same way, different kinds of oral contraceptive pills don’t all work the same way, and have different risks and benefits that need to be weighed when choosing between them. While many patients may indeed be able to do that kind of analysis, many physicians think that decision should be made in consultation with a doctor.

    Having seen a 35 year old woman die because she was on OCP, and smoking* (something she lied to her dotor about), I can tell you that oral contraceptives are not as straight forward to manage as a condom. Thats the theory behind having a doctor involved, not trying to wrest reproductive control out of the hands of women.

    *Smoking and OCP both increase risk of blood clots forming in the legs, which can then go to your lungs, a serious condition called pulmonary embolous, which can be fatal.

  8. #8 Courtney
    March 19, 2009

    That’s true that being stupid about OCPs can kill you. So can aspirin, and an 8 year old can buy that. Still not convined that OCPs should require a prescription.

  9. #9 PalMD
    March 19, 2009

    Once again, i think reasonable people can disagree, but i think your analogy is weak. Aspirin is unlikely to be harmful if used as directed. OCPs, not so much. Still, I do see your point.

  10. #10 Whitecoat Tales
    March 19, 2009

    Lets be clear, I’m NOT saying that OCPs should be prescription only, I see both sides of the issue and I’m torn on the subject.
    I was just explaining the rationale so that you could see the argument for prescription only OCP as something other than a way to deprive women of their right to choose (please excuse me if I’m oversimplifying)

  11. #11 llewelly
    March 20, 2009

    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.

    Do you have data which indicates said counseling improves the health of patients?
    (Whitecoat Tales gives a suggestive anecdote, but I would like to know if someone has data.)

  12. #12 Whitecoat tales
    March 20, 2009

    My anecdote isn’t even that suggestive- the woman in question did have physician counseling.

  13. #13 DuWayne
    March 20, 2009

    I have very mixed feelings about making OCP’s OTC. The issue of discussing it with a physician or nurse technician (such as one would probably see at Planned Parenthood) is really important – especially for women going on for the first time. While it is easy to say that a women could still do so, it is unlikely that everyone would. How many people talk to their doctor before starting on most OTCs? And there are a lot of dangers to using OCPs that really should be made clear before starting on them.

    The other issue I have with it, is the issue of drug coverage. A lot of insurance carriers stop paying for scripts that become available OTC. This is not an insignificant concern.

    I do think that the morning after pill should be available OTC, with a great many warnings. Given the timeframe for efficacy, I just think it’s important that it be available without the need to see the doctor.

    As far as the notion that healthcare professionals are bound by different ethical requirements.

    A pharmacist becomes a pharmacist knowing exactly what that job entails and what their ethical requirements are. They are not a fucking doctor, who can choose a specialty. They have a very generalized job that requires they serve patients of all sorts, including those who have elective health concerns.

    Pal would not be the doctor to go to for cosmetic surgery. I have my doubts that he would be capable of providing such services, because he’s an internist. Likewise, I wouldn’t think that Orac would be a very reasonable doctor to see about heart palpitations or depression issues. He’s an oncologist – not an internist or heart specialist. It would be highly unethical for either Pal or Orac to step outside their area of expertise.

    A pharmacist just dispenses meds and utilizes their knowledge to make sure that the drugs they are dispensing are unlikely to harm the patient due to medical error on the part of the doctor or because their is evidence that the patient in question is a drug abuser. Beyond that, they have a ethical duty to fill scripts – period. If they aren’t comfortable with dispensing certain meds, there are plenty of other options for them to pursue in health care that would eliminate their ethical concerns.

  14. #14 Corey
    March 22, 2009

    I think this discussion on OCPs is fairly interesting considering that I am currently on my OB/GYN rotation doing clinic at a large urban hospital that treats mostly the uninsured. There seems to be an argument over availability of resources, but not so much one about education. Something I’ve seen a lot from patients is just a lack of education about contraception. Most of them have heard of OCPs, and they know that OCPs keep them from getting pregnant, but they don’t have a lot of other information. They don’t know about the risk of clots if they combine OCP use with smoking as mentioned above, but some of them also believe that using an OCP will help prevent disease or will hurt their fertility in the future.
    Another problem is that patients aren’t educated about the alternatives to OCPs if they don’t see their OB/GYN. Over the past week I’ve seen multiple patients walk in for new OB visits because they hadn’t taken their OCPs because of nausea and didn’t know about any of the myriad options out there.
    While I totally believe in reproductive freedom and fully support contraception, education is severely lacking for the public as well as for practitioners and supplying birth control OTC will not help that.

  15. #15 Courtney
    March 22, 2009

    I’m all for education.

    That said, when I was a lowly undergraduate, and p.o.’d at the fuckwittitude of only making female students undergo exams in order to receive b.c., I discussed various b.c. with my Student Health provider. She mentioned that when used properly, condoms having a 99% protection rate. Problem is, people are either stupid or ignorant, and fail to use condoms properly, thus chucking their protective rate down to 85%. I asked for an example, and she gave one of people only putting on a condom immediately prior to orgasm. Condoms are OTC. Yeah, they won’t kill you, but using them improperly can (see also: AIDS).

    My health class in high school gave demonstrations of proper use! What more do people need? (I’m feeling particularly intolerant today!)

    This is why I think that birth control should be mandatory, and you should get a permit to do without.

    But that’s just me.

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