Medical Right Watch

Medical Right Objects to ACOG Opinion Patient Referrals

By Cynthia Cooper

Medical Right doctors have been fuming for months over a recommendation in November 2007 by the American College of Obstetricians and Gynecologists (ACOG) that called for doctors who object to providing certain services on moral grounds to refer to another doctor who will perform the service.

The recommendation was part of Opinion #385 by the ACOG Committee on Ethics, “The Limits of Conscientious Refusal in Reproductive Medicine.” The six-page opinion also offered other guidance for those who decline to provide reproductive health services because of moral or religious objections.

These organizations that RCRC characterizes as the "Medical Right" - including the Christian Medical Association, Pharmacists for Life, Focus on the Family and Family Research Council - were particularly incensed over the suggestion that doctors who oppose abortion should provide a referral for patients seeking this service. They consider a referral to be as morally offensive to themselves as the abortion itself.

The issue erupted publicly on March 14 when U.S. Heath and Human Services Secretary Michael Leavitt issued a press release calling for a rejection of the Ethics Opinion and protection of “the conscience right of physicians.”
Leavitt also wrote a letter of “concern” to ACOG and the certifying board for gynecologists and obstetricians, ABOG, opposing any use of the Ethics Opinion #385 in certification of doctors and threatening that such an action could jeopardize federal funding.

The Religious Coalition for Reproductive Choice supported ACOG's “fair-minded policy.”

A three-year RCRC study by theologians, ethicists, healthcare professionals and healthcare activists, “In Good Conscience, Guidelines for the Ethical Provision of Healthcare in a Pluralistic Society,” concluded that a doctor’s conscientious objection cannot be at the cost of patient care.

Thrust of Opinion on Conscientious Objections

The ACOG Ethics Opinion does not suggest that doctors are required to provide abortion or other services to which they object, except in an emergency. It does state that physicians“have the duty to refer patients in a timely manner to other providers if they do not feel they can in conscience provide the standard reproductive services that patients request.”

The Ethics Opinion cites examples of women who were denied reproductive health care based on the moral perspective of the healthcare provider. One example in the Ethics Opinion is of a 42-year-old Virginia mother who was refused a prescription for emergency contraception and became pregnant. Another is of a 19-year-old Nebraska woman with a life-threatening pulmonary embolism who had to be taken by ambulance to a second hospital after a religiously-affiliated institution refused a first-trimester abortion.

The Ethics Opinion (see Abstract below) states that refusals of service should occur only if “the primary duty to the patient can be fulfilled.” It states that doctors should provide accurate and unbiased information; give prior notice to potential patients if they deviate from standard practices; refer for services they do not provide; provide services in an emergency that would affect a patient’s physical or mental health; and locate in proximity to doctors who can provide the services they decline to offer.

Immediate Objections By Medical Right Groups

Medical Right objections began quickly after the Ethics Opinion was published. On December 7, 2007, Dr. David Stevens, Chief Executive Officer of the Christian Medical Association, and representatives from 26 other organizations sent a letter to ACOG, calling for “the repudiation and withdrawal” of the Ethics Opinion.

Dr. Stevens and the co-signers said that the Ethics Opinion reflected “an underlying bias against persons of faith,” was “a message of ideological intolerance and religious discrimination,” and amounted to “disenfranchisement” of doctors who oppose abortion.

Conscientious refusals, they said, are not a matter of subjective feeling but based “on the objective teachings of Scripture - the same Scriptures that have provided the foundation for the laws of much of civilization.”

The ACOG Ethics Opinion tried to balance both the physicians' and patients' needs. ACOG advised that conscientious refusals should be limited if they impose religious or moral beliefs on patients. The Medical Right organizations, on the other hand, said that allowing patients to obtain services to which their doctor objected on moral grounds would “have the practical effect of reducing physicians to the pawns of patients.” Dr. Stevens and the co-signers said that referring patients for abortion is no different from performing abortions - at least on principle - and objecting doctors cannot be asked “to recommend someone else to do the deed.” The suggestion that doctors provide “accurate and unbiased information,” they said, would inappropriately force pro-life doctors to offer abortion as an option. They said the suggestion that doctors who will refuse care should locate near doctors who offer it was "incredible."

Others of the Medical Right who co-signed the letter included representatives from the Catholic Medical Association, American Association of Pro-Life Obstetricians and Gynecologists, Concerned Women for America, Pharmacists for Life, Focus on the Family and Family Research Council.

Multiple Fronts for Response

The Medical Right groups also responded individually. The American Association of Pro-Life Obstetricians and Gynecologists issued a statement of strong objection on February 6, 2008. “It is of great concern that this committee opinion repeatedly describes elective abortion, and other controversial reproductive medical procedures and services as ‘standard,’” the AAPLOG president said.

The Catholic Medical Association called on ACOG to rescind its opinion, comparing abortion to crimes against humanity in Nazi Germany, the Tuskegee Syphillis Study and involuntary sterilizations of women. “The Opinion fails to do justice to the ethical issue of cooperation in evil raised by providing referrals for abortion and, indeed, dismisses concerns about complicity in gravely immoral actions,” the Catholic Medical Association said.

The Christian Medical Association took its case to the President’s Council on Bioethics only two days after it was published. The Bioethics Council is chaired by Dr. Edmund D. Pellegrino, a member of a circle of advisors to the Family Research Council. On November 9, 2007, Jonathan Imody, Washington D.C. representative of the Christian Medical Association, made a public statement at healthcare hearings of the Bioethics Commission about the ACOG Ethics Opinion and “the war that is being waged against conscience rights.”

This commentary may have reached HHS Secretary Leavitt. Leavitt’s appointed Acting Deputy Assistant for Population Affairs, responsible for family planning issues, is Dr. Susan Orr, a former director at the Family Research Council. Orr, who previously opposed contraception coverage in private healthcare plans, replaced another controversial anti-contraception appointee, Dr. Eric Keroack, who resigned after a short tenure.

Leavitt’s letter to ACOG and ABOG was hailed by the Medical Right and its many news outlets. The Family Research Council and U.S. Conference of Catholic Bishops issued press releases commending Leavitt.

In addition, “threats to conscience rights” and the ACOG opinion are scheduled as the topic for the Midwest Regional Bioethics Conference on April 26, 2008, in Madison, Wisconsin. The conference is sponsored by a state chapter of the Catholic Medical Association, with support from the Christian Medical and Dental Associations (another name for the Christian Medical Association).

Response from ACOG

The American College of Obstetricians and Gynecologists, in a March 26, 2008, response to members from Dr. Kenneth L. Noller, president, said that the Ethics Opinion is guidance and does not force action or affect certification. “We want to be clear the Opinion does not compel any Fellow to perform any procedure which he or she finds to be in conflict with his or her conscience,” he wrote. Dr. Noller said the Ethics Opinion is not part of the Code of Professional Conduct and does not affect certification or membership in ACOG.

Because of “uncertain and mixed interpretation” to the opinion “the Executive Committee has instructed the Committee on Ethics to hold a special meeting as soon as possible to reevaluate ACOG Committee Opinion #385.”

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The Abstract of the ACOG Committee on Ethics Opinion on “The Limits of Conscientious Refusal in Reproductive Medicine” states:

Health care providers occasionally may find that providing indicated, even standard, care would present for them a personal moral problem -- a conflict of conscience -- particularly in the field of reproductive medicine. Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled. All health care providers must provide accurate and unbiased information so that patients can make informed decisions. Where conscience implores physicians to deviate from standard practices, they must provide potential patients with accurate and prior notice of their personal moral commitments. Physicians and other health care providers have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. In resource-poor areas, access to safe and legal reproductive services should be maintained. Providers with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient’s physical or mental health, providers have an obligation to provide medically indicated and requested care.

Written March 28, 2008, posted April 4, 2008

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