As expected, the Bush administration finalized its proposed "provider conscience" rule last week. Despite opposition from leading medical groups like the American Medical Association, the American College of Obstetricians and Gynecologists, and the American Hospital Association; from Senators, House members, and state attorneys general; from officials at the Equal Employment Opportunity Commission; and from over 200,000 individual commentators, the Health and Human Services Department pushed through a rule that expands the right of health care workers to refuse to provide medical care, counseling, referrals, and even information to an unprecedented level.
The rule is pernicious in many ways. It allows all employees, and even volunteers, of most institutions receiving HHS dollars to deny access to a wide variety of medical services. The rule ostensibly protects only employees who object to abortion and sterilization, but it is written so broadly that it could also apply to contraception, fertility treatments, HIV/AIDS services, gender reassignment, end-of-life care, or any other medical practice to which someone might have a personal moral (not even religious) objection.
This rule is not "just a woman’s issue," though the more than 17 million women who depend on our public health system and who are disproportionately low-income and women of color will certainly bear the largest brunt of this politically-motivated regulation. The rule also provides a striking example of how the stigmatization of one medical service-specifically, abortion-can quickly creep into other areas and erode well-established medical standards of care. Allowing medical services to be ranked on a scale of moral superiority is a public health problem.
The right of conscience is an important and time-honored value in our society and one that should not be tread upon lightly. But it is not only health providers who have rights; so do patients. Standards of care and codes of conduct exist to balance the rights of them both. Instead of pitting the rights of providers and patients against one another, perhaps there are a few tenets upon which we as a society can agree:
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- Withholding relevant, medical information from patients is never good medical practice nor ethical;
- In emergency situations, the patient’s medical needs must always come first;
- Providers who are unwilling to provide certain services must give their patients timely notice of their refusal to do so and must refer those patients to a provider who can supply the needed health care.
Despite the fact that professional medical associations have consistently endorsed these precepts, the new HHS rule ignores all three of these basic yet essential codes. Fortunately, it is likely that the new administration and the new Congress will work to reverse this rule as quickly as possible. But this debate will not end with the demise of this rule, and we must not countenance some very dangerous concepts that have been advanced in support of the rule.
Requiring a health care provider to do his or her job is not discrimination. Employers are required to accommodate an employee’s religious beliefs when doing so does not present an undue hardship on the employer. However, refusal or withdrawal of health care in a manner that neglects a patient’s needs is an undue hardship and should not be entitled to accommodation.
Providing a referral for a service is not morally equivalent to providing that service yourself. There are varying degrees to which one’s conscience may be burdened by certain actions. Supplying information about where to find appropriate medical care ought not to tax one’s conscience to the same extent as performing a procedure or dispensing medication. Moral beliefs exist along a continuum and the protections afforded for such beliefs must be proportionate as well.
A refusal to provide care can harm patients. In our current health care system, we face a shortage of primary care physicians, a nursing shortage, a vast population of uninsured and underinsured patients, hospitals that cannot afford to stay open, and rural communities with few health care resources like clinics and pharmacies. Health care providers should not assume that just because they say no, a patient will be able to find another provider who will say yes who is also affordable and accessible.
The so-called "provider conscience" rule disrupts the careful balance established by medical codes of conduct and standards of care, placing the health, well-being, and dignity of patients at risk. We must work to ensure the proper balance is restored quickly, so that we can continue to protect the right of conscience while also protecting access to all health care services for every patient who needs them.
This article was first posted at Science Progress.