Denials of contraception and other standard, legal medical care are becoming more common amongst religiously conservative physicians:
“I’ll need the morning-after pill,” she told him.Dr. Gish looked up. He was a trim, middle-aged man with graying hair and, Boyer thought, an aloof manner. “No,” Boyer says he replied abruptly. “I can’t do that.” He turned back to his writing.
Boyer stared in disbelief. No? She tried vainly to hold back tears as she reasoned with the doctor: She was midcycle, putting her in danger of getting pregnant. Emergency contraception is most effective within a short time frame, ideally 72 hours. If he wasn’t willing to write an EC prescription, she’d be glad to see a different doctor. Dr. Gish simply shook his head. “It’s against my religion,” he said, according to Boyer.
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People on both sides of the debate are making a stand where none need be made.
Take three oral contraceptive pills and be done with it.
If you have an established relationship with a physician form whom prescription of contraception would be ordinary care then you should expect oral contraceptives; any restrictions he might have on his practice should be disclosed to the patient as a matter of having previously beginning a doctor-patient relationship.
If this is the first meeting of this doc by the patient, then the doc is under no obligation to you with care that he does not provide for any of his established patients. Just becaues you show up on his clinic doorstep demanding something in particular does not oblige himm to provide it.
Patients at risk for pregnancy (and therefore at risk for other health conditions associated with intercourse) need an established relationship with a doc who can provide basic gyn care. Upon establishing an initial visit with a doc you want to know what care the doc might not be forthcomming with. The doc should be willing to disclose what he won’t do because he does not want a later confrontation with his patients.
The doc’s position on various issues might be an indulgence of his conscience, but is also simple marketing to a niche. There are people who are happier to be seen in an office where they know that there is not a suction D and C going on in the next room or otherwise the provision of care that they find immoral or repulsive.
“But Boyer remained haunted by the ER doctor’s refusal — so profoundly, she hasn’t been to see a gynecologist in the two and a half years since. “I haven’t gotten the nerve up to go, for fear of being judged again,” she says.”
But she wasn’t judged. By her report of Dr. Gish’s words, he merely stated “it’s against my religion”. He did not state that she was wrong for having her own differing religious beliefs. It is no more a judgement than if my jewish partner passes on a ham and cheese sandwich I am offering.
Failing to go to a gynecologist or other physician who practices basic gyn care is her own damn fault. How is she to have this very problem addressed in the future unless she looks out for her own needs. She can continue to feel vitimized or control those elements of her life that she can.
Anon 12:59, you obviously did not read the story.
She went to the emergency room after being sexually assaulted.
This was apparently not her regular doctor, it was the doc who happened to be working in the ED that night.
If a physician doesn’t want to prescribe emergency contraception in his/her office practice, that’s fine, although I think this should be disclosed up front so patients are aware of it and can choose to go elsewhere if they want.
It is a different matter when someone shows up at the ED after being raped. She was in a very vulnerable condition and didn’t have the luxury of picking and choosing at her leisure which doc she would see.
I don’t think any health care professional should be forced into providing care that goes against his/her beliefs, but given the particular circumstances of this patient’s situation, this guy should have referred her to someone else for what she needed.
Did the hospital have a policy about how to handle this kind of situation? If not, they were at fault too. In fact, theirs may be the greater fault, since it was their ED.
Yes, I did read the story. I was commenting on the subject in general. This story is just one variation on the various played out in the press by interested groups.
The solution is to have contraception available over the counter. Alternatively, the hospital could have a standing order for it so that it can be dispensed as a prn by any nurse for indication. Some health care is so basic and low risk that there is no reason to filter it through a physician in the first place.
A good reason why some things need to be outside a doctors control and in the hands of the individual.
The solution is to have contraception available over the counter. Alternatively, the hospital could have a standing order for it so that it can be dispensed as a prn by any nurse for indication.
While this is a good solution, if she was sexually assaulted and needed a pill right there she hardly had time to lobby for OTC contraceptives.
Bottom line is – she needed emergency care. She was denied it.
“A good reason why some things need to be outside a doctors control and in the hands of the individual.”
A doctor is also and individual and has a right to decide what activities are worthy of his labor and which are not. I do not need a law to tell me that I am free to decide what services to provide and to whom I shall provide them. If they law tells me to do something that I morally object to, then the law is immoral and I will violate it.
This issue is just more of the rampant race to eliminate personal freedom in our society. People are not only not willing to die and kill for their neighbor’s freedom, they aren’t even willing to be inconvenienced or have their feelings hurt.
I consider medicine to be first and foremost a moral enterprise and it is as personal to the doctor as it is to the patient. I know a urologist who will not do vasectomies. I know another who will only do them on a married man if the wife consents. I know another who thinks that policy in indefensible. They each have the right to run their practice accordingly.
Yes, patient rights need to be protected and respected. But a patient’s right to a physician’s consultation at an ER does not extend to receiving whatever care the patient deems appropriate.
Physicians are independent consultants with a duty to serve the public. There is a balance here that needs to be struck between physician independence (including moral independence!) and protection of the public safety.
Medicine is heavily based upon the beneficence of the physician – that the physician will do what he/she thinks is best for the patient. And the public faith in this beneficence is what motivates people to trust their doctor. But it is critical to remember that this beneficence is grounded on the moral integrity of the physician. If we force physicians to act against their conscience, we are damaging the very basis of moral beneficent medicine.
So yes, there needs to be standards to prevent discrimination and to ensure that patients are properly informed.
I would suggest that if a physician morally objects to a treatment considered part of the standard of care, that he/she:
1.) Inform that patient of the available options, including the one he/she objects to.
2.) State that he/she does not provide such a treatment due to personal moral objections.
3.) Physicians in family practice clinics or gynecologists could have a sign at their registration desk that indicates that they do not provide contraception / emergency contraception / elective abortions to avoid confrontations at difficult times.
Finally, an analogy:
Canada does not extradite prisoners to countries where the prisoner might face capital punishment or torture unless a guarantee of their life and safety is obtained. Why? Because Canada, as a country, has chosen to protect its moral integrity by not only refusing to participate in these acts, but also in refusing to provide others with access to prisoners for such reasons.
Other countries may (justifiably) disagree with Canada’s view on these matters, but at least Canada should be able to protect its own moral integrity. Should we condemn doctors for doing the same?
Richard, any doctor who refuses to provide an indicated, safe and effective treatment to an injured person should not be allowed to serve in an ED. The hospital didn’t have to contract with that doctor to provide care, and the hospital should be required to provide that care in order to have an ED.
Period.
There is no excuse for failing to provide emergency contraception to a sexual assault victim presenting in an ED shortly after an assault.
I agree that the ER doc should have provided the emergency contraception or found another doc who was able to. However, all of the rest of the examples are blown out of proportion by an author with an agenda. Her own statement is very telling:
“In the end, the women in all of the incidents above were able to get the treatment they wanted, even if they had to go elsewhere.”
So doctors should abdicate their moral beliefs for pt convenience? This is an example of the happy meal mentality of Americans and illustrates why national health will never work in this country. Americans with their demands for health care services will never allow it to work. Very simply in other NHS countries, if the doc tells you he isn’t doing it, it won’t happen.
Well then if he wants to refuse emergency treatment following a rape, and she is indeed pregnant, maybe that Doc. should then adopt this child who has the genes of a rapist and raise him/her as his own. You know since he is so moral and all.
In the specific example shown, it is natural to empathize with the rape victim, and to demonize the doctor. But no matter how I and 99% of the rest of us feel about it, we do not have the right to compell him to do what he thinks to be wrong.
As long as the problem is one of invconvenience and hurt feeligs, the value of ones right to not be compelled to act against ones own conscience clearly trumps those lesser concerns.
Even if he is being a stuborn bonehead, he has the right to be a stubborn bonehead.
“we do not have the right to compell him to do what he thinks to be wrong. “
Correct but he does have the requirement of finding a doc who will address this issue.
>”Correct but he does have the requirement of finding a doc who will address this issue.
# posted by Anonymous : 10:15 AM”
I am not even so sure about that. He doesn’t become an unwilling facilitator or procurer by electing not to provide by presription treatment he regards as morally abhorrent. It isn’t either-or.
He can suggest the patient find another provider, but he is not required to secure that referral. That would be morally equivalent to providing the treatment himself.
And the notion of “emergency” contraception, even in cases of alleged criminal sexual assault, challenges the real notion of emergency treatment. Unlike preventative antibiotics, which could be given in an assault to prevent infection from the assault, contraception is a categorically different issue, albeit presenting a possibility equally unwanted. Calling it “emergency care” is a logical sleight of hand, since pregnancy is not a disease (ironically the argument made by the same folks who want to call contraception a “treatment”).
I agree with the poster above that contraceptives of the kind requested should be made available over-the counter, no prescriptions required.
That gets you around the doctors and pharmacists whose personal scruples seem to conflict with their abilities to satisfy patients and customers.
I think you are walking a fine line anon 11:14. The doc is seeing the pt in a professional capacity, He has duty to this patient. This duty may not include prescribing the meds himself. But it does include referring the pt to someone who will in the time required. I think the vast majority of docs and risk management people would disagree with you on this one. The other examples in the article are nothing more than an overblown agenda on the extremely biased journalist’s part.
There is no fine line at all here. Yes, he is seeing the patient in a professional capacity (sort of obvious, I hope). But your notion of referring to someone else “in the time required” begs a larger question here. If he feels the use of a contraceptive is morally repugnant, why should he be compelled to assist a patient in obtaining such at all, even if not by his own prescription? If you allow the right to refuse, as the law evidently does, then you allow, by extension, the right to refuse referral for the same. Refusal does not imply a subsequent time-limited obligation to refer to another doctor who you believe must assure a treatment deemed inappropriate by the first doctor. This isn’t the same situation as if the patient presented with a fracture beyond the capacity of the E.R. doctor to treat, where referral to the orthopedist is made to provide timely definitive treatment. The referral is made not merely because the patient may or may not want referral, but also (or in spite of, perhaps) because the doctor wants the patient to have the treatment. You appear to want to make these cases alike; they are not.
In the post-assault case, contraception is seen as not necessary, not recommended and not desired as a “treatment” for the patient (regardless what you personally think of that). In the assault case, the doctor is not similarly required to facilitate a treatment he does not believe is necessary or right (the law, not your opinion obtaining.)
Your position in this case is to make the doctor not a moral actor, but a sort of half-puppet, someone who if he chooses to refuse one thing as morally wrong must then be compelled to effect the same end by proxy. Being a professional, having a license, working in an emergency department makes no such requirement that that be the case.
Your suggestion that somehow this demand represents “emergency care” and that by not referring to another for the prescription of contraception he somehow is practicing substandard care. Providing medication prescriptions on demand is not “care”, to start.
The law allows him to refuse to provide prescriptions for contraception. Even though the circumstances appear compelling, even though the patient was supposedly sexually assaulted and wants–very reasonably, I think–to avoid an unwanted pregnancy subsequent to that crime, the patient is demanding medications to prevent an outcome that is not considered a disease. Demanding emergency “treatment” for the same is
oxymoronic. Pregnancy (voluntary or involuntary) cannot be at once a condition to be prevented under emergency treatment terms and at the same time a natural condition and not a disease.
So after-contact contraception is really not something that belongs in the realm of of required treatment to meet a “standard of care”, which says nothing about it not being available or desirable.
Risk management people can be afraid of their own shadows sometimes. If the institution where this doctor works does not require automatic prescribing of “morning after” drugs on demand, and the law permits doctor discretion, then he is right to refuse.
If you disagree, write your state legislator. Better yet, ask that these medications be available without a prescription.
Look, I am not going to get into circular academic arguments with you that go nowhere. Talk with your risk management/medical director and see what they say. I think you will be surprised.
What makes them “academic” if what we are discussing is practice? I don’t think this is “academic.”
And there isn’t any circularity that goes nowhere, the argument goes squarely against prescribing on demand.
That was the point of the article: that you can’t go to a doctor and demand whatever you want, even in the emergency room, even if what you want is legal and is accepted practice. People are just amazed that the voluntary nature of care works two ways. The world doesn’t all work lik Burger King.
Leaving beside the emergency room subject for a moment, there’s another situation involving office-based care that puzzles me.
If a doctor doesn’t want to be involved in birth control or sterilizations, why wouldn’t that person be up front about it, before a patient makes an appointment with him or her. The doctor could have a brochure in their office that states their stance on birth control. They could have this information up on their practice website and/or the webpage that their local hospital has for them. If a new patient calls their office, the receptionist should tell that person about the doctor’s policies.
That way, no patient wanting birth control would make an appointment with that doctor (though there’s an awful lot of women who have a strong interest in birth control; it’s a lot of patients). The doctor doesn’t waste his time with a patient he won’t treat.
Personally, I’d want to know if a family doctor or gynecologist I see has such strong beliefs. I’m beyond the age where I need birth control, but I still wouldn’t want to be cared for by someone who puts his/her beliefs first.
but I still wouldn’t want to be cared for by someone who puts his/her beliefs first.
Hmmm…
What if they believe you are not ill and you disagree? What if they believe you are very ill, and you disagree? Should they not put their beliefs first? What if, contarary to popular practice, they believe a certain treatment is harmful? Would the doctor have been wrong to prescrivbe vioxx to you 2 years ago if he/she “believed” that it may not be beneficial, but harmful? Or should your demands and “beliefs” come first?
Who is the professional, and who is seeking advice?
Oops –
post should read “wrong to not prescribe Vioxx”
I should have been more clear, I meant religious/moral beliefs. I did not mean medical beliefs/expertise/advice.
It would be an interesting to do a survey asking women if they would want to go to an ob/gyn who refuses to dispense birth control, even if they are not in need of contraception themselves.
Personally, I cannot fathom why anyone would become an ob/gyn who has such hard and fast rules regarding birth control.
If a doctor is willing to override his moral scrupples for your gratification, how likely is he to honor them when his own gratification is at stake? . . . his desire for more riches? . . . for sexual contact? . . . for power?
If you’re a Jehova’s Witness and an MD, can you refuse to offer your patient a blood transfusion because it is against your morals?
If a man were to present to the ER with upper left quadrant chest pain, would it be appropriate for the ER doctor to refuse to examine him because it’s against her religion to touch men? Or refuse to refer him to another doctor because the only other doctor working the ER that night was also a woman, albeit not of the same religious belief?
Would it be appropriate for a hospital to hire ER physicians who refused to examine opposite-sexed patients because their religions tell them it’s immodest? And who denied them access to other doctors of the opposite sex?
We’re talking about standard care here. You might genuinely believe that interfering with the transmission of life is playing God, but if you are going to serve a secular public you need to be able to cope with a secular world in which contraception is a neutral act.
You might genuinely believe that for a woman to be in the presence of a man without being escorted by her husband, or for her to touch any man who is not her husband or son, is a sin against the separation of sexes instituted by God. But if you are going to serve a mixed-gendered world in a secular world, you need to find a way to cope. You cannot simply refuse care. It’s reasonable to expect examination and treatment for upper left quadrant chest pain in your local ER. Likewise, it’s reasonable to expect the offer of emergency contraception as part of your care when you’ve been raped. This isn’t about “gratification.”
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