“Conscience” and Reproductive Health Care

Health Care Refusals: Undermining the Medical Standard of Care for Women | “When There’s a Heartbeat: Miscarriage Management in Catholic-owned Hospitals” | Institutional Influence on Obstetrician-Gynecologists’ Patient Care Practices

Ultrasound machine
The term “conscience” has meant different things over the years with regard to reproductive health care. Before abortion was legal, many physicians were moved by their conscience, their sense of what was morally right and necessary, to provide illegal—but safe—abortion care. (This is the subject of Carole Joffe’s 1995 book Doctors of Conscience.) More recently, the term “conscience clause” can be found regularly in the media in reference to legal protections granted to health care personnel who refuse to provide health information and services based on their personal beliefs.

While health care providers have always had the legal right to abstain from performing abortions, conscience clauses (now extending to pharmacists, nurses, and others) have become an increasingly salient and powerful political tool of the Prolife Movement. (See Resources on Provider “Conscience” Issues for news coverage of these conscience clauses, legal and social science analyses, and more.) The clauses protect not only individuals but also institutions, which often impose ideologically based restrictions on the health care that clinicians in their system can provide. Since the 1990s, Catholic health care institutions in particular have grown dramatically, and now own a significant portion of hospitals and managed care systems in the United States.

The tension between the “conscience” rights of the institution, the clinician, and the patient generates pressing bioethical questions worthy of investigation. Additionally, there has been no rigorous analysis examining the extent to which denials of care affect the overall health of women, particularly low-income women whose choice of health providers is often limited. ANSIRH is currently involved in several projects seeking to fill this knowledge gap.

Health Care Refusals: Undermining the Medical Standard of Care for Women is a collaborative project with the National Health Law Program (NHeLP). Dr. Tracy Weitz and Susan Berke Fogel, JD of NHelp investigate and document whether and to what extent these denials conflict with professionally developed, accepted medical standards of care, and analyzes the potential health consequences to patients. This analysis provides a new framework for evaluating refusal clauses and denials of care, hospital mergers, and other transactions when they conflict with accepted and expected medical practice.

The project team has compiled a report that provides background and analysis of the ethical and legal concepts of standards of care and informed consent, and then analyzes religious, ideological and political restrictions and denials of care that conflict with and undermine established medical standards. It also provides detailed descriptions and analysis of the standards of care that govern medical practice for a range of common health conditions and illustrates how refusals and denials of care violate those standards and put women’s health at risk. Read the report.

“When There’s a Heartbeat: Miscarriage Management in Catholic-owned Hospitals.” During the course of conducting dissertation research on obstetrics and gynecology training and practice, Dr. Lori Freedman conducted physician interviews which revealed that miscarriages are managed differently in Catholic hospitals when the fetal heartbeat is still detectable. Some physicians expressed frustration when their ethics committee would not approve uterine evacuation in these cases because the Directives equated it with abortion, even when miscarriage was inevitable. Therefore doctors reported transporting their patients to non-Catholic facilities or waiting for the patient to become infected and sick enough to compromise her life, at which point the ethics committee would approve the intervention. These findings were published in American Journal of Public Health in October 2008 and motivated Dr. Freedman to further investigate the impact of Catholic health care on patients.

Institutional Influences on Obstetrician-Gynecologists’ Patient Care Practices. Dr. Lori Freedman, in collaboration with Dr. Debra Stulberg and her team at the University of Chicago, is conducting a qualitative, interview-based study about 1) national variations in obstetrician-gynecologists’ beliefs and practices around sexual and reproductive health care and 2) hospital or practice-related factors that influence how they care for their patients. While the patient-doctor relationship has received much attention, little is known about an often-hidden third party in this relationship: the hospital or practice that employs or credentials the physician. Thus, the study aims to gain fresh insight into the bedside bioethics of religiously affiliated health care institutions and their employees.