Bioethics is the field of ethics that deals with complex cases which arise in the field of medicine. Physicians have been governed by the professional codes of ethics from the days of Hippocrates to the present day. Medical ethics used to revolve solely around paternalism, which included what physicians can do to advance their patients’ best interests in regard to their health. However, now it is more directed towards patient’s autonomy and involves including patients in their health care decision making [9]. There are four bioethical Principles which every physician should adhere to in order to promote the well-being of the patient. The bioethical principles are as following: 1) autonomy: an individual’s right to make informed healthcare decisions for him or herself 2) beneficence: any actions that benefit another individual 3) nonmaleficence: prevent or remove harm 4) justice: distributive and comparative. Professionalism in medicine includes following all four of the bioethical principles while serving the patient population and prioritizing the patients’ best interests over their own [4]. In this paper, I will be discussing how a physician’s right to refuse providing care and certain services in the name of their personal and religious beliefs may violate the very root of professionalism and the core bioethical principles.
The United States has a diverse community of physicians, in terms of culture, religion, and country of origin. Contrasting views on legal yet controversial issues such as reproductive rights (including birth control and abortion services) give rise to the ongoing debate of whether physicians should be allowed to refuse services based upon their beliefs. Physicians, like all people under the United States Constitution, are protected by law against the infringement of their religious beliefs, however, physicians who implement personal conscience and refuse to provide services on the grounds of religious or moral beliefs may violate medical professional ethics. The relationship of a physician and patient is based on mutual obligation similar to most other ethical relationships [7]. A doctor’s duty is to provide care for a patient while allowing autonomy. By allowing a doctor to refuse procedures based upon their own beliefs, a patient may no longer have a choice and therefore is no longer allowed the autonomy to act in their own best interest. Also, the imposition of a physician’s religious and personal beliefs may infringe upon a patient’s own beliefs and are itself, akin to discrimination [3]. Critics also argue that refusals solely based on physician’s religious or personal values makes patient’s access to health care services much harder as they have to rely on physician’s beliefs [1]. By limiting a patient’s access to health care, a refusal based on personal beliefs may also violate ethical principles of beneficence and nonmaleficence by unintentionally causing harm.
Asking a physician to put aside his personal beliefs or religious commitments is violating his/her constitutional rights, however a physician has an obligation to avoid an action that may be deemed harmful to her patient [7]. Even the courts recognize this potential harm, especially when moral obligations conflict with ethical obligations, and thus physicians who refuse to provide all the necessary information may also face legal implications. For example, in 2004, a Pennsylvania court case arose in which a physician refused to perform an abortion. In this case the physician was protected under state law allowing for the refusal of a procedure based upon religious beliefs, however, the court held the physician accountable for malpractice for failure of full informed consent by not disclosing the potential dangers that the mother would face if she didn’t seek an abortion from another physician [5]. This example shows that withholding important information is not only unethical within the realm of medical bioethics by violating beneficence and nonmaleficence, but it also violates legal principles. The patient is more vulnerable in circumstances where such conflicts arise as they may not have access to all available information and they may be relying on their physician for discussion of diagnosis, treatment options, side-effects etc.
When a physician’s religious values prevent him/her from caring for their patients, to avoid conflict, one option can be to give a consent, referring to such objections in their initial interaction with their patients; however, if the same conflict rises once the relationship has been established the case is viewed under a different light [2]. For example, if a physician refuses to provide the requested medical intervention, it would be morally and legally unacceptable if her/she terminate that relationship without referring the patient to another provider, and it is considered ‘abandonment’ both morally and ethically speaking [7]. If a conflict does arise due to physician’s personal values, he/she should make every effort for an appropriate transfer of the patient and their information to another provider who can provide the objected services. If a physician does not provide the patient with a referral to an alternative doctor, it would be a violation of two of the core principles, beneficence and nonmaleficence. For instance, if a physician refuses to give a patient an abortion pill like Misoprostol, which could induce medical abortion for up to 9 weeks since last menstrual period, now not only has the physician violated beneficence but also violated nonmaleficence by forcing the patient to obtain a surgical abortion which carries higher risks.
A study done by American College of Obstetrics and Gynecology (ACOG) stated that in areas where the medical resources are limited, physicians who have an objection to provide full range of reproductive services should practice in proximity to another physician who does not share the same views as the objecting physician [6]. According to ACOG, physicians should ensure that referral procedures are in place in case a physician has an objection to any of the reproductive rights of a particular patient [6]. By providing a referral to another physician, both the doctor’s beliefs and patient’s autonomy are not infringed upon. In addition to a referral, it is imperative that a physician review all treatment options with the patient despite their personal beliefs, therefore allowing the patient to act in their own best interest and seek medical care from a different physician if necessary.
Wardle suggests that opinions requesting to impose limits on how physicians can implement their religious beliefs, specifically reproductive care providers, does not acknowledge that protection of morality is a “fundamental right and not merely a convenient accessory” [8]. Physicians are allowed to refuse or accept patients for their care due to their own moral objections by law but once the patient-physician relationship exists, the American Medical Association recognizes that it is an ethical duty to provide a necessary referral and all the related information [2]. There are federal legislations in place that protect physicians against discrimination, however, these legislations do not support those physicians who may rob patients of their legal rights, for example: access to reproductive care and other necessary medical interventions, by implementing their religious or moral beliefs.
Physicians’ have a moral obligation to ensure that a patient is not being deprived of the legally available medical care, despite their own religious beliefs. When conflicts arise, physicians’ have to make a compromise and refer their patient to another physician who can provide that medical intervention, provide all available information and treatment options to fulfill their Hippocratic oath, and the professional code of ethics. By doing so, not only will physicians be fulfilling their ethical obligations, but this will also ensure that the patient receives the best possible care.