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Soodtida Tangpraphaphorn

November 24, 2003

PM 508

Should Health Care Providers be Allowed to Opt Out of Providing Certain Services Because of their Religious Beliefs?

In non-emergency cases, it is a health provider’s right to be allowed to choose which procedures he or she wishes to practice and not to practice. If personal moral beliefs prevent a health care provider from practicing in good conscience, then he or she should be permitted to abstain from performing those particular procedures. Specifically, if a physician deems a service such as elective abortion to be morally objectionable, that physician reserves the right to refuse to offer elective abortions. To compel the physician to relinquish that right would be to violate his or her civil liberties.

In order to discuss whether people have the inalienable right to make personal choices, we must first examine the meaning of choice. In this context, the physician needs to choose whether it is more important to serve the patient or to obey his or her personal ethic. Should the physician choose to serve the patient, the patient receives the services he or she needs, but in exchange the doctor’s emotional, psychological and spiritual well-being are adversely affected. Worse yet, if the doctor cannot practice in good conscience, there is a strong chance that the quality of care will suffer. On the other hand, if a doctor chooses not to offer a particular service, he or she may bear a clear conscience at the end of the day, but access to those services may become limited.

Personal freedom and choices are not only political, but also philosophical. Eighteenth Century Danish philosopher Søren Kierkegaard had many ideas about the nature of personal choices made in the context of society. He taught that the unconditional personal commitment to a higher cause is greater than adhering to the universal ethic because that is what defines people as individuals (as opposed to mere units of a populace). Guided by this principle, Kierkegaard would argue that it would be wrong to deny an individual the ability to remain committed to his cause. If that cause happened to be a physician’s principled commitment to protecting life (including a rejection of abortion practices), then in the context of this philosophical framework it is not worth sacrificing that principle to comply with what is seen to be a benefit to the population at large. The basis for American politics also speaks to this ideal; American society as a whole, from its earliest inception places a huge emphasis on the individual over the whole society.

In the United States, advocates on both sides of the issue of physician choice are turning to the Constitution for guidance. In such cases, it is fair to cite Amendment IX and Amendment X from the Bill of Rights. They are quoted as follows:

Amendment IX

“The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.”

Amendment X

“The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.”

While it would be convenient to cite an article of the Constitution concretely enumerating a doctor’s obligation to serve his patients regardless of personal objections, there is no such provision. Instead, because health care is not a right enumerated in the Constitution (“life, liberty and the pursuit of happiness” are often wrongly cited in these arguments; they were artifacts of the Declaration of Independence), American policymakers are allowed to interpret the Constitutional Amendments that ensure that the rights not specifically stated and protected are to be decided by the states and the people. Accordingly, state and local governments handle health care issues for their communities. But because the topic of pregnancy termination is such a volatile one, there are no laws compelling physicians to offer abortion services; physicians are allowed to decide for themselves whether to offer those services. This is in sharp contrast to the socialized health care system in place in Canada where medical doctors are required to perform abortion services regardless of personal convictions involving the procedure. In Canada, the argument is that as an employee of the government, it is the physician’s obligation to serve the people fo the greater good of society. On a practical level, Canadian taxpayer money funds their practices; therefore the physicians must do what they are being paid for. While American physicians may take these differences for granted, changes in the way medical colleges instruct their students may affect a practitioner’s freedom to decide for himself.

Americans have valued personal freedom since the inception of the United States; personal freedom is one of the founding principles of America, and there are many people who feel very strongly about it. While American society does not strictly oppose the idea of social welfare, our devotion to the principle of individual liberty sometimes comes at the expense of social welfare. A notable example of this would be our right to choose private health care providers, but our lack of universal health care coverage.

In the medical community, the debate rages over whether the need to provide elective abortions to patients requiring such treatment supercedes the right of doctors to refuse to perform such services. Some feel very strongly that in the interest of maintaining patient access to abortion services, doctors should forsake their own interests in favor of serving their patients. Others feel that because abortion is such a moral hot topic, forcing a doctor to perform abortion services when they are against his or her morals would be a violation of his or her civil liberties.

Recently, lobbying in favor of expanding elective abortion instruction has resulted in the amending of obstetric and gynecology curriculum guidelines by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is the private organization in charge of ensuring that medical schools are properly training their students and that quality of the education stays above their set standards. Medical degrees from medical colleges without ACGME accreditation are often perceived as invalid; therefore it is in the school’s best interest to adhere to ACGME guidelines in order to earn their seal of approval. However, in 1996 ACGME implemented new guidelines for obstetrics and gynecology residency programs requiring that elective abortion training be part of the curriculum in all accredited medical programs without religious objections to the practice. Schools that do not comply with the amended guidelines risk losing their accreditation.

While pro-choice groups lauded this revision as a political victory, pro-life groups cried foul, claiming that it would be culturally insensitive towards religiously devout students (especially those at medical colleges with no religious affiliation) and impede on medical students’ right to opt out of procedures they find morally reprehensible. Two key stakeholders in the debate are: Medical Students for Choice and the American Association of Pro-Life Obstetricians and Gynecologists.

Medical Students for Choice is a North American organization dedicated to increasing the number of physicians who provide elective abortion services by “working to destigmatize abortion provision among medical students and to persuade medical schools to include abortion as a part of the reproductive health services curriculum.” Their mission statement states that their goals are to build a support network for future abortion providers, reform medical curricula to make abortion training standard, and to raise awareness among policy makers and the public about the need for more abortion training. They cite provider shortages (thus restriction to access) and lack of instruction and training as reasons to advocate the new guidelines implemented by the ACGME. The numbers of abortion providers have been declining since the 1970s, as have residency programs offering elective abortion training (from 23% of programs in 1985 to 12% of programs in 1992). However, Medical Students for Choice does have reason to applaud. According to a study in Family Planning Perspectives in 2000, since the implementation of the new guidelines, opportunities for abortion training have been on the rise (up to about 40% after being on a consistent decline for the past several decades). The following date is from a study done by the Alan Guttmacher Institute.

|Percentage distribution of obstetrics and gynecology residency programs, by availability of |

|first-trimester abortion training, according to year of survey |

|Year |Offered routinely |Offered as elective |Not offered† |Total |

|1998 |

|Assumption A |46 |34 |19 |100 |

|Assumption B† |31 |23 |44 |100 |

|1992 |12 |58 |30 |100 |

|1985 |23 |50 |28 |100 |

|†Includes programs where residents may obtain training elsewhere. †Percentages do not add to 100 |

|because some respondents did not indicate whether training is routine or elective. Notes: Under |

|assumption A, nonrespondents offer abortion training at the same rate as respondents. Under |

|assumption B, all nonrespondents, who make up 31% of the survey universe, do not offer abortion |

|training. |

On the other hand the American Association of Pro-Life Obstetricians and Gynecologists, a non-religious special-interest group recognized by and situated within the American College of Obstetrics and Gynecology, strongly opposes the ACGME curriculum revisions. They argue that curricula that were standard prior to the ACGME revisions outlining training in dilatation and curettage (D&C), prostin evacuation, suction curettage and treatment of post-partum infection were adequate and sufficient because all of the procedures are employed during elective abortions, but are also applied in cases of complications during miscarriage. AAPLOG opposes the revisions because they feel it is unnecessary to intentionally terminate a pregnancy to perform procedures that could be taught satisfactorily in a spontaneously aborting case (miscarriage).

Assuming that really there are no procedural differences between D&C, prostin evacuation, etc. performed in the context of miscarriage and elective abortion, then this would debunk Medical Students for Choice’s claim that curriculum reform and mandatory elective abortion training are necessary to ensure that practicing abortion providers are available. This claim does not even address the concern that doctors simply choose not to practice abortions. After all, even if medical students complete their residency with a certain number of hours of elective abortion training, how can these pro-choice groups ensure that those students go on to provide abortions in their regular practices? Simply changing the curriculum will not do that. Instead, they may do better to shift their focus towards encouraging students (who can still receive satisfactory training under older guidelines) to actually practice as abortion providers. This way, no student who wishes to undergo abortion training will be compelled to do so, but pro-choice activists will still be able to affect an increase in available providers. This will also mean that the ACGME guidelines would be redundant and unnecessary, allowing for their repeal.

Should the ACGME guidelines remain in place, how will they be interpreted in the long run? What is likely to happen is that unless provisions are made to ensure that students’ rights to object to elective abortion training are protected, medical students who personally oppose abortion will be intimidated into complying with elective abortion training, leading pro-life students to suffer as they begrudgingly practice a procedure that they oppose so strongly simply because they need to earn their degree. This is not fair by any means.

In response to the implementation of the ACGME guidelines, and as a means of preventing implementation of similar regulations by the government (a bill in California and a new law in New York echo the ACGME revisions, but instead of simply being under the governance of a private organization, the enforcement of mandatory elective abortion training will become state policy), pro-life lobbyists have gone to the federal level to oppose and help create legislation to overturn these measures. Although it is not certain what the outcome of their political action will be, because the current administration is more sympathetic to their concerns, the pro-life lobby is optimistic they can enact their proposals.

While I recognize that it is necessary to have abortion providers available in order to ensure a woman’s right to choose, the methods implemented to expand the pool of providers cause unnecessary harm to the students who will become health service providers in the future. The regulations imposed by ACGME and the states of California and New York will only serve to deter otherwise bright and qualified students who happen to be anti-abortion from applying to or enrolling in medical programs, or distress those who do enroll by having them practice a procedure they object to very strongly. I support reproductive choice and favor encouraging willing physicians to provide abortion services, but I simply cannot agree with mandatory abortion training requirements. There are other means of increasing the number of physicians who perform elective abortions that do not require governmental intervention or controversial curriculum requirements. Gains can be made by raising the profile of elective courses in abortion training, or by forging strong partnerships with family planning organizations in the nearby community to enable students to train in pregnancy termination procedures. This way, the students who want to participate are not deprived of a valuable learning experience, and those who choose to opt out need not worry about their studies imposing on their beliefs.

The core values of American society as we know them presently tend to value personal choice over providing for a common good. We call these personal choices civil liberties. While their numbers may seem small, there will still be a contingent of doctors who choose to perform elective abortions. Via means of activism that do not include curriculum regulation, we can increase the number of abortion providers without impinging on people’s rights to practice their beliefs. In this way, we can continue to protect women’s right of reproductive choice without infringing on the civil liberties of medical professionals.

Bibliography

Ameling R, Tews L, Dudley S. Abortion training in U.S. obstetrics and gynecology residency programs, 1998. Family Planning Perspectives. 2000, 32(6):268-271 & 320

American Association of Pro-Life Obstetricians and Gynecologists. Welcome to AAPLOG. May 26, 2003. Available at: . Accessed November 10, 2003.

American Medical Association. American Medical Association Homepage. 2003. Available at: . Accessed November 10, 2003.

Thomas Legislative Information. Historical Documents. 2003. Available at: . Accessed November 10, 2003.

Medical Students for Choice. Medical Students for Choice: home. 2003. Available at: . Accessed November 10, 2003.

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