Case Scenario

At one of our group-practice meetings, we agreed that we could not require partners to perform services to which they had moral objections. For example, some of us had wanted to offer our patients medical abortion, but we had agreed that none of us would offer this service so we could accommodate the views of our other partners. The discussion led to some soul searching, during which time some of our physicians said that they were morally opposed to prescribing birth control. We therefore agreed that, in keeping with our effort to present a unified policy, we also could not offer prescription birth control.

However, this conclusion created an uncomfortable situation because it meant that to accommodate the religious views of some of our physicians, we would have to deny important medical services to thousands of patients who did not have many health care options.

In addition, the moral issues became economic issues because so many of our patients come to us seeking contraceptive management. Many patients became angry and left our practice when they were told that their physician would no longer prescribe birth control. The issue threatened to break up our group.

Commentary

This case concerns the justification of moral constraints that a physician group decides to apply to itself in the provision of patient services. Family physicians confront this issue with regard to reproductive medical services and state laws such as those in Oregon regarding physician-assisted suicide. Whether such constraints are ethically justified depends on the distinction between professional medical ethics and individual conscience.^1,2

Professional medical ethics are concerned with the obligations that any physician has to his or her patients. When the provision of a medical service violates professional medical ethics, no physician is ethically permitted to provide that service. For example, if an adult child who is exhausted from caring for a parent with advanced dementia asks the parent's physician to administer a lethal injection to the parent, the physician should deny the request. The killing is not being requested to benefit the patient; it is requested without the patient's consent; and it is in violation of the central requirements proposed for the professional medical-ethical justification of physician-assisted suicide.³

Strictly speaking, objections to abortion or contraception by physicians do not rise to the level of objections based on professional medical ethics. Abortion (including contraception that contains abortifacients), while a matter of controversy, is legal and consistent with professional medical ethics.^1,2 Objections to abortion and to contraceptives that do not involve abortifacients typically appeal to religious or theologic principles. Professional medical ethics is secular and, therefore, is not determined on such grounds. Thus it follows that physician objections to abortion and contraception appeal to individual conscience.

Appeals to individual conscience must be taken seriously as a matter of respect for the individual physician's autonomy.^1,2 Thus, respect for individual conscience creates ethical challenges for a physician group. One acceptable position is for the group to agree not to provide medical services that any member of the group finds morally objectionable on the grounds of individual conscience. This decision may involve nontrivial financial sacrifice for all members, a matter that should be acknowledged and carefully assessed.

A second option is to dissolve the group to respect the individual conscience of all group members. This alternative may also involve economic penalties.

A third option is for the group practice to continue with some members providing services and others not. As a matter of individual integrity, members with serious moral objections to the services in question should not benefit financially from the provision of those services. Therefore, different levels of compensation should be considered.

No matter which option is chosen, the physicians in this group are bound by professional ethics in the following respects. First, the ethics of informed consent require that women of child-bearing potential, as a matter of routine in their primary care, be offered information about medically reasonable alternatives for preventing pregnancy, including contraception. Second, pregnant women have the right to know that abortion before viability is a legal option. Legitimate moral objections to the performance of contraceptive or abortion services, based on individual conscience, require that women who desire contraceptive or abortion services have access through appropriate referral to health professionals who can meet their medical needs.⁴

Finally, if the group adopts the first or third option, the members have a medical-ethical responsibility toward their patients regarding informed consent. There is an obligation to explain the group's constraints on reproductive medical services. In the first option, all potential patients should be informed that no member of the group provides the reproductive medical services in question. In the third option, all potential patients should be informed about the specific physicians who do not provide these services.

In modern pluralistic societies, managing the clinical and ethical implications of distinguishing between professional medical ethics and individual conscience should be regarded as a basic skill for all physicians who work in groups.