Bioethics Forum Essay

Tennessee’s Inappropriate Reliance on Conscientious Objection

“You keep using that word. I do not think it means what you think it means,” Inigo Montoya to Vizzini in The Princess Bride

Imagine this scenario: You are newly pregnant and seeking care with a physician. And in discussing your medical history you are asked if you are married–you are not–and then you are told you will have to look elsewhere for prenatal care. This recently happened, according to reporting from Tennessee.

In the report, the pregnant woman said that the doctor refused to treat her, citing the Tennessee Medical Ethics Defense Act. The act, which became effective on April 29 of this year, ostensibly provides protection for clinicians who refuse to provide care because that care violates a “sincerely held ethical, moral, or religious beliefs or principles.” Federal protections for conscientious objection have existed for years. Yet Tennessee and some other states have introduced stronger language. The pregnant woman in Tennessee, speaking  at a town hall, said that the physician told her that because she was unwed, they didn’t feel comfortable treating her because that went against their values and that she should seek care elsewhere. The patient is now receiving prenatal care with another clinician in Virginia.

It’s not clear from reporting if the Tennessee clinician felt they could deny care because of the passage of the act or would have done so anyway. Physicians can legally decline to accept patients into their practice and thus deny care absent  an emergency. Legal protections, like Title VII of the Civil Rights Act, exist against discrimination in the workplace but don’t specifically extend to establishing a patient-physician relationship or even providing medical care. The AMA Code of Ethics acknowledges the contractual aspect of medical care, noting, “physicians are not ethically required to accept all prospective patients.”  However, the AMA goes on to caution that physicians “should be thoughtful in exercising their right to choose whom to serve” and notes specifically that such refusals should not be due to “personal or social characteristics that are not clinically relevant to the individual’s care.”  Importantly, the AMA points out that physicians “should not decline patients for whom they have accepted a contractual obligation to provide care,” which may be the case if physicians accept Medicaid (as is the case with the woman in Tennessee).

Conscientious objection is defined as “the refusal of a health care professional to provide or participate in the delivery of a legal, medically appropriate health care service to a patient because of personal beliefs.”  The objection should focus primarily on the procedure or intervention and, as noted by the AMA, not the personal characteristics of the patient. To do otherwise–to refuse care to a patient because you disagree with their life choices, as is the case here–makes a mockery of the term “medical ethics.”

The word ethics simply doesn’t mean what this clinician–or Tennessee or the federal government–takes it to mean. And attempts to use this term to defend unethical behavior are inexcusable. Professional medical ethics demand that we treat all patients equally. We have a duty to provide compassionate care to every person regardless of whether we agree or disagree with how they live their lives.

Meeting this ethical duty is celebrated in other contexts. I live and work in Boston, and after the marathon bombing physicians and nurses ensured that the bombing victims and the bomber received the highest standard of care. In my own practice, I provide care to all patients who seek it. As a Jewish physician I have cared for patients who are white supremacists. I disagree with them vehemently and believe their views are abhorrent, but I would never deny them care. Almost all religions, and specifically Judeo-Christian traditions, emphasize love, compassion, and service as foundational elements for providing care to others.

Those who conscientiously refuse provision of certain types of care do have an ethical right to do so. But this narrow exception to our duty of care must remain narrow and not expand so grotesquely as to encompass an objection to the person in front of you. Our professional ethics and most religious traditions do not permit this–whether you place the words “medical ethics” in the title of the act or not.

Louise P. King, JD, MD, is the director of reproductive bioethics at the Harvard Medical School Center for Bioethics and a member of the board of trustees of The Hastings Center for Bioethics.