There are many things that physicians are called upon to do that challenge their personal morality. Some might not agree that a 21-year-old woman with five kids living on medical assistance should have an infertility work-up when she does not conceive within 12 months. Some might not agree that a woman should receive an abortion, or even contraception for that matter. Some of my colleagues will neither perform abortion nor refer to a physician who offers the procedure. Some pharmacists will not fill prescriptions for emergency contraception (EC), because of a religious, rather than scientific, belief that life begins at conception.
I have a real problem with all of this, of course. Physicians should not impose their own morality upon their patients, period. Take the case of pharmacists who refuse to fill legal prescriptions for emergency contraception. For starters, they are interfering with the doctor-patient relationship. They are also stepping in and imposing their own medical judgment, which is neither appropriate nor in keeping with their non-physician role as pharmacists. Nothing against pharmacists—I come from a long line of them—but they are not accredited to render clinical judgment. So long as the prescription is legible, properly filled out and there are no contraindications such as known allergies, their role is to professionally fill the prescription.
And given all the misconceptions (no pun intended) regarding EC, it’s may also be an issue for medications that actually are part of the medical abortion regimen. Misoprostol is an antiulcer drug that is part of two standard medical abortion regimens. It may also be used, however, as an adjunct to labor induction, and also to manage spontaneous abortion (miscarriage). Imagine if a woman presents to a pharmacy to fill a misoprostol prescription due to peptic ulcer disease. A pharmacist might suspect the woman is really going to use the medication as part of a medical abortion regimen and if that is not okay with his or her morality, refuse to fill the prescription. Despite the patient’s protestations that she’s taking it for ulcers. Mind you, she is also coming in with a valid, legal prescription signed by her doctor.
Similarly, many hospital emergency rooms decline to offer EC to women who have been sexually assaulted, despite the fact that this is considered standard care by several professional organizations. Again, here are health care professionals, my colleagues, imposing their own world view upon their patients.
I raise this issue, having read an interesting article in the Washington Post about a “right of conscience” for health care professionals. It goes beyond the more common issue of pharmacists refusing to fill EC prescriptions, raising scenarios like a reproductive endocrinologist refusing to provide artificial insemination to a lesbian. Of particular interest, the article also brings up the issue of anesthesiologists refusing out of conscience to attend executions by lethal injection.
Now, I think there’s a difference between a physician refusing to officiate at an execution and a pharmacist refusing to fill a prescription for EC or for a drug that could be used in the context of medical abortion. Physicians and other health professionals have a primary duty to their patients. They may decline to perform a procedure, but must refer the patient to a colleague who does offer the procedure (pharmacists, however, have the responsibility to fill a proper prescription and not insert their clinical interests before that of the patient and her physician). Physicians, however, have no primary duty to the state in terms of supervising and assisting in executions. We’re not talking about euthanasia, but state-run execution. It actually violates most physician professional codes of ethics to assist in an execution.
Still, issues of conscience remain contentious, and not easy to solve. My personal preference is to not inject my morality into the practice of medicine. We can’t expect our patients to do what we would do ourselves. When we insert ourselves into the role of parent or deity, rather than physician, we overstep our boundaries and potentially violate our patient’s autonomy and even their civil liberties.