To Do Or Not To Do is that even a question?

1. To Do Or Not To Dois that even a question? Conscientious refusal in medicine

3. Real life

5. Conscience • The private, constant, ethically attuned part of the human character. It operates as an internal sanction that comes into play through critical reflection about a certain action. • Conscientious refusal involves the provider's right to protect his/her moral integrity—to uphold the "soundness, reliability, wholeness and integration of [one's] moral character". • ObstetGynecol2007;110:1203-8.

6. Roe v Wade 1973 Supreme Court case which effectively legalized abortion based on right to privacy issues.

7. Church Amendments • Federal laws that were put into place starting in 1974 to prevent discrimination against medical professionals who refused to participate in abortions or sterilizations within healthcare facilities that received federal funding. These laws make clear that individual providers or healthcare institutions have no obligation to perform abortions or sterilizations as a condition of receiving government payments.

8. Employment Division, Department of Human Resources of Oregon vs. Smith, 494 U.S. 872 (1990) Supreme Court case that determined that the state could deny unemployment benefits to a person fired for violating a state prohibition on the use of peyote, even though the use of the drug was part of a religious ritual.

9. Religious Freedom Restoration Act 1993 • Government shall not substantially burden a person’s exercise of religion even if the burden results from a rule of general applicability.

10. Rules of GA Board of Pharmacy • (n) Refusal to Fill Prescription. It shall not be considered unprofessional conduct for any pharmacist to refuse to fill any prescription based on his/her professional judgment or ethical or moral beliefs. • Authority: O.C.G.A. §§ 43-1-19, 26-4-4, 26-4-28, 26-4-60, 26-4-80, 26-4-82, 26-4-110, 26-4-113, and 26-4-115.

11. CASE STUDY

12. You are the Director of the OB/GYN Clerkship at Great Eastern University School of Medicine.  During clinic hours this morning, you and a third year medical student encounter a 17 year old single Catholic female who is an unregistered immigrant. She fears that she may be pregnant from an unprotected sexual encounter 4 days ago. She does NOT want her parents involved. She requests a prescription for “ella (Ulipristal acetate).” She does not have access to any other healthcare facility.

13. Shortly after the young woman describes her situation, the medical student quietly and politely excuses herself from the exam room.  You finish the encounter and leave the room to find the medical student waiting quietly outside the door.  She apologizes for leaving and explains that she is morally opposed to any form of “abortion” including emergency contraception and cannot conscientiously participate in any patient encounter where this is involved. She requests that you excuse her from involvement in any case where this is likely to be discussed or provided.

14. All second year students at Great Eastern Medical School are required to participate in the clinical skills curriculum, a part of which involves demonstrating that they can perform a complete physical exam on a female patient.  Mr. X refuses to participate on the basis that he is a devout Muslim and interacting with a female patient in this manner would violate his religious beliefs.  He is an otherwise exemplary student and has actively participated in every other aspect of the curriculum.  There are no models available that would allow him to demonstrate proficiency without the use of a female standardized patient.

15. AMA Policy H-295.896 Conscience Clause: Final Report The AMA has set out seven principles to guide exemption of medical students from activities to which they object for reasons of conscience. The Association recommends that discussion about conflicts of conscience be part of the regular curriculum, that medical schools establish procedures to allow students to be exempted from activities for religious or ethical reasons, and that students be apprised of the policies. https://download.ama-assn.org/.../PolicyFinder/policyfiles/.../H-295.896

16. Problems with conscience clauses • Right to privacy - Is an individual denied her right to decide whether to use contraception when a doctor refuses to provide the service? • Equal Protection – Do CC’s sanction unequal treatment of men and women? • Justice – Lack of access for women in low-income or rural areas, for whom a refusal to prescribe may cut off access to contraceptives entirely.