We want to make sure that we stop it before it starts. It’s so much easier to prevent bad medicine than it is to stop it after it’s started.
– Arkansas Rep. Julie Mayberry (R-East End) speaking on Arkansas Public Radio about SB-53, a bill that restricts medical abortions by preventing them via telemedicine — an unfortunate development for the 78 percent of Arkansas women who don’t live near one of the state’s three abortion clinics.
When did government get in the business of practicing medicine?
The doctor-patient relationship is based on truth, intimacy, and trust. We ask questions of our patients that most people would deem intrusive or even offensive. But our invitation to do so is implied by the fact that our patients enlist us to help protect them from illness and injury. This access to our patients’ most private spaces is in part what makes doctoring such a privilege.
Of course, in return for letting us know them so intimately, patients reasonably assume that we will be truthful and honest and that we will hold their interests above all others’ and that we will adhere to the Hippocratic Oath and the four ethical principles that guide the doctor-patient relationship: autonomy, beneficence, nonmaleficence and justice.
Our ability to take care of patients depends centrally on the strength of the doctor-patient relationship, on an open line of communication running in both directions, and on our ability to practice in accordance with these tenets of our profession.
Unfortunately, the sanctity of this relationship — so broadly recognized as vital that it traditionally has been protected as privileged communication under the law — is under serious assault.
In 1973, Roe v. Wade recognized that the Constitution protected a woman’s right to terminate a pregnancy and placed the decision in the hands of conscientious physicians and their patients. But in the years since, governors across the country have enacted hundreds of restrictions on abortion and other reproductive health services – including 231 since the midterm elections of 2010. And the trend continues: As of this writing, states have advanced no fewer than 100 additional bills that further restrict women’s ability to make timely, private and appropriately informed decisions about their pregnancies, their health, and their families.
But beyond the impact on our patients, these statutes also affect physicians in unprecedented ways. Among these laws are some that infringe on our right to free speech, compel us to commit harmful acts toward our patients, and threaten the ethical underpinnings of our profession.
- In five states doctors, are required to tell their patients that personhood begins at conception, even though imposing personal or philosophical views under the guise of medicine is both a direct violation of patient autonomy and an overt abuse of physician power.
- In North Dakota, Texas and Ohio, physicians must follow an outdated FDA label when providing early medical abortions, notwithstanding the fact that more than 20 years of evidence accumulated since demonstrate the superiority of a more effective and less costly regimen that has fewer side effects.
- In Arizona, a law protects doctors who intentionally withhold from pregnant women information about fetal anomalies, while in Virginia a law permits genetic counselors to withhold information they believe will lead a woman to choose an abortion. Deliberately concealing the results of a medical test is unethical, yet clinicians who do so are shielded from the censure of our profession.
- In several states, including Texas, Kansas, South Dakota and West Virginia, doctors must tell any woman who seeks a surgical abortion that the procedure may increase her risk of getting breast cancer, committing suicide, becoming infertile, and experiencing severe psychological distress — all claims refuted by the best medical research.
- In thirteen states, abortion providers must perform an ultrasound on every woman seeking a termination irrespective of a medical indication to do so. And in three of those states, providers are required to show and describe the ultrasound image whether or not the patient consents.
In the world of reproductive health, we doctors are being forced to inflict emotional pain and psychological stress on our patients. We are being required to say and do things we know to be contrary to established scientific evidence. We are being compelled to lie to our patients for purely political reasons.
But it is not just the relationship between doctors who perform abortions and their patients that is in jeopardy. Increasingly, legislators are inserting themselves between physicians of all specialties and their patients. This legislation has alarming and far-reaching consequences that extend beyond the realm of family planning.
In fifteen states, all health care professionals must report confirmed and even suspected prenatal substance use to law enforcement, a blatant violation of doctor-patient confidentiality. As a consequence, in Tennessee alone nine women have already been arrested for the now prosecutable crime of substance abuse in pregnancy. Such laws not only deter those women most in need of treatment from seeking it; they also destroy the safe space between patients and physicians, precluding honest dialog that is critical to providing good care.
Elsewhere, in Florida — where accidental gun violence alone accounts for $57 million of hospital costs – a law now prohibits physicians from inquiring about firearms in the home, a screening measure recommended by the American Academy of Pediatrics. When 11,000 state health providers challenged the law as a violation of their First Amendment rights, a federal appellate court ruled that the law did not violate physician free speech but rather merely regulated physician conduct. Indeed, the court observed that the government has broad authority to prohibit doctors from asking questions on any number of topics in the name of protecting patient privacy.
Such censorship of physician speech could have a much broader effect on the practice of medicine. What if other topics were also declared off-limits? After all, just as exercising the right to bear arms is a private choice, so too is the decision to drive without a seat belt, to forgo sunscreen at the beach, to remove batteries from home smoke detectors, to ride a motorcycle without a helmet, to eat, smoke and drink whatever amount, to have protected or unprotected sex with men, women or both.
How can it be within the jurisdiction of state legislators — neither trained in the provision of health care nor subject to the Hippocratic oath — to undermine the doctor-patient relationship, to decide how health is discussed, how illness gets treated and how providers and patients must communicate with each other?
We can no longer take for granted that we are entitled, by our long training and the oath we take, to have private, confidential conversations with our patients; to speak freely and practice honestly in our patients’ best interests; and to provide care under a contract that we and our patients — and no one else — write together.
Ultimately, every physician in every specialty must examine his or her conscience and decide whether and how to add his or her voice to defend the integrity of the profession, the uninfringed rights and health of our patients, and the sanctity of doctor-patient communications and relationships. Unwarranted government interference in our exam rooms threaten both the practice of medicine itself and, more importantly, those who entrust us with their health and lives. Let us not be complacent but rather join in common action to speak out against this assault on our profession.
Abigail S. Cutler is an obstetrics-gynecology resident. Nancy L. Stanwood is board chair, Physicians for Reproductive Health.