An EMT instructed to transport a woman to an abortion clinic declines, citing personal beliefs. A nurse ordered to administer a large dose of morphine to a terminal cancer patient in pain refuses, saying the medication could hasten death. A physician turns away a gay patient, apparently on the basis of his sexual orientation.
Are these scenarios examples of healthcare workers asserting their right of individual conscience, or are they unethical, perhaps illicit denials of patients' rights to receive medically appropriate treatments?
This question is at the center of a simmering debate that is moving beyond pharmacists who refuse to dispense contraceptives to other hot-button issues, such as in vitro fertilization, physician-assisted suicide and stem-cell research, affecting a wide variety of specialties in healthcare. Although there's no reliable statistical evidence that more US healthcare workers are refusing to treat on moral grounds, anecdotal evidence indicates the phenomenon is growing. A variety of bills and laws, mainly on the state level, either grant or deny healthcare workers the right to refuse treatment.
Healthcare Workers' Conscience vs. Patients' Rights
The disagreement is deeply entrenched.
"This is a conflict of the constitutionally based right of conscience and the patient's right of convenience," says Dr. David Stevens, executive director of the Christian Medical & Dental Associations.
Others say healthcare workers who refuse to provide treatment are breaching their professional duty to put the patient first.
Present and future healthcare workers need to know that these legal, ethical and ideological battles threaten to alter professional relationships and change career arcs.
Employer-Employee Communication Makes a Difference
Partisans on both sides say it's important for healthcare workers to inform their employers about what procedures they won't perform -- before they are asked to perform them. Some jurisdictions require such notification.
"A California law requires that pharmacists reveal to their employers which treatments they won't provide," says Judy Waxman, vice president for health and reproductive rights at the National Women's Law Center.
Conversely, healthcare employers have a duty to inform job candidates if they won't tolerate treatment refusals. "Companies need to lay out the terms of the job and the expectations when workers are hired," says Arthur Caplan, director of the University of Pennsylvania Center for Bioethics.
Some assert that Title VII of the Civil Rights Act of 1964 forces employers to share the burden of reconciling workers' beliefs with patients' rights. "When an employee makes a request based on religious belief, the employer must attempt a reasonable accommodation but need not take on an undue hardship," says Francis Manion, senior counsel for the American Center for Law & Justice, which represents healthcare workers who have refused to treat.
Still, workers who decline to provide treatment run the risk of alienating peers. "Coworkers will think you're nuts or evil, but that's just how life is," says Kevin McDonnell, a philosophy professor at all-female Saint Mary's College, which is affiliated with the Roman Catholic Church, and a specialist in medical ethics.
Personal Beliefs May Impact Career Choices
Those considering a healthcare career or job change should reflect on how their beliefs align with potential job duties. "Some medical students are required to do abortions, and most of our premed students won't do them, so they're going to have a big fight," McDonnell says.
On the other hand, healthcare workers who believe they must provide any medically appropriate treatment may find themselves curtailed in some settings.
"If you go and work in a Catholic hospital, you are under Catholic healthcare directives, (and) you're ruled by what the bishops and the pope say," Waxman says. "Healthcare workers need to know how their activities may be limited by these directives."
Treatment of Gays and Lesbians Is Also a Battleground
Some healthcare providers deny or limit the care they provide gays and lesbians. "I may not approve of homosexuality, but that doesn't mean I don't treat them," Stevens says. "But I don't help homosexuals conceive children."
Says Jennifer Pizer, senior counsel for Lambda Legal, which advocates for the rights of gays and lesbians: "There's a great obligation on the part of a religious believer to find an occupation where their practice won't injure third parties," such as lesbian patients seeking artificial insemination. "Having a religious motive for the conduct doesn't take away the harm."