The U.S. media and state and federalpolicymakers have devoted a greatdeal of attention this year to the issueof pharmacists refusing to dispenseemergency contraception and otherprescription contraceptives. Littleabout this issue is, in fact, new; poli-cymakers have engaged for decadesin an ever-broadening debate overwhether and in what circumstancesindividuals or institutions involved inthe provision of health care or relatedservices can refuse to provide ser-vices or information on moral or reli-gious grounds (“New Refusal ClausesShatter Balance Between Provider‘Conscience,’ Patient Needs,” TGR,August 2004, page 1).

What has often been absent fromthis debate over providers’ rights hasbeen any serious discussion aboutproviders’ responsibilities—to theirpatients, colleagues, employers andthe public. Some of these obligationsare encoded in law; perhaps moreimportantly, they are enshrined inprofessional codes of ethics thatdefine what it means to be a healthcare professional and supplementedby individual professional associa-tions’ policy statements on variousissues.

The Values at Stake

Although different associations andprofessions frame the issues differ-ently, core values that are generallyagreed upon across health care pro-fessions and in the field of bioethicsunderlie the rights and the responsi-bilities of all health care providers:

• Beneficence requires the providerto act in the best interest of the

patient and her welfare and is close-ly related to nonmaleficence, thebasic obligation to do no harm.

• Justice underlies the principle ofnondiscrimination and the obligationof health care providers to work forthe public good.

• Respect for autonomy leads to suchprinciples as informed consent andconfidentiality, as well as respect forthe decisions of colleagues.

These core values have been trans-lated into more specific ethical prin-ciples by numerous professionalassociations. Such guidelines arenecessary in part because these val-ues can at times conflict or appearto point in different directions. Inthe absence of respect for autonomy,for instance, beneficence can easilyturn into paternalism in the hands ofa highly trained health care providercaring for patients with inferiorknowledge. And, while the Interna-tional Code of Medical Ethics of theWorld Medical Association (WMA)asserts that “a physician shall alwaysbear in mind the obligation of pre-serving human life,” in a separatedeclaration on abortion, the WMAdiscusses how the “diversity of atti-tudes towards the life of the unbornchild” can lead to differences in howto interpret this obligation. Profes-sional standards help to mediatethese differences.

Despite the complexities of balanc-ing these values, the professionalmedical associations have beenremarkably consistent when itcomes to the concept of refusal. Inessence, professional standards typi-cally endorse a provider’s right to

step away, or “withdraw,” from pro-viding a health care service that vio-lates his or her moral or religiousbeliefs. At the same time, these stan-dards make clear that there must belimits to this right in order to ensurethat patients receive the informa-tion, services and dignity to whichthey are entitled (see box, page 8).

Although not always spelled out inone place or in every association’sguidelines, this balancing leads to sev-eral clear obligations, including that:

• providers must impart full, accu-rate and unbiased information sopatients can make informed deci-sions about their health care;

• patients must always have accessto services in emergency circum-stances;

• providers must not abandonpatients but instead must refer themto another provider willing andready to take over care; and

• providers seeking to “step away”must give adequate and timelynotice to patients, employers andothers who will be affected by theirdoing so.

It should come as no surprise thatmany of the most detailed standardsand policy statements about refusalfocus on abortion, contraception andother forms of reproductive healthcare, along with end-of-life care.These services have often generatedcontroversy among policymakers andthe general public. The professionalassociations have made their posi-tion clear, however: A health careprovider’s moral or religious beliefscannot justify attempts to override apatient’s autonomy. The right towithdraw from services cannot beused as a pretext for blocking ordenying patients’ own rights to care.

Responsibility and Reality

Public policy, however, has notalways matched up with the princi-ples endorsed by professional med-

Rights vs. Responsibilities:Professional Standards andProvider Refusals

By Adam Sonfield

Issues & Implications

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ical associations, and the situationappears to be getting worse. Withinweeks of the U.S. Supreme Court’sdecision in Roe v. Wade that legal-ized abortion nationwide in 1973,Congress passed legislation proposedby then-senator Frank Church (R-ID) to ensure providers’ ability towithdraw (“Refusing to Participate inHealth Care: A Continuing Debate,”TGR, February 2000, page 8). TheChurch Amendment prevents the

government (as a condition of a fed-eral grant) from requiring healthcare providers or institutions to per-form or assist in abortion or steril-ization procedures against theirmoral or religious convictions. Italso prevents institutions receivingcertain federal funds from takingaction against personnel because oftheir participation, nonparticipationor beliefs about abortion or steriliza-tion. The question is not specifically

addressed, but nothing in this policysuggests that anyone has the right towithhold information from a patientor refuse to refer a patient to anoth-er provider.

Almost every state in the countryalso has decades-old policies allow-ing individual health care providersto refuse to participate in abortion;many of these laws also apply tosterilization, and in 10 states, tocontraception more broadly. Theselaws often depart more explicitlythan the Church Amendment fromthe professional standards discussedabove: Only a handful of these lawsspecifically provide an exception torefusal rights in emergency circum-stances; most do not require healthcare providers to notify theiremployers if they intend to opt-outof certain services, and only threerequire any notice to patients; andabout a dozen go so far as to allowproviders to refuse to provide infor-mation, despite the broadly recog-nized obligations around obtainingpatients’ informed consent.

The architects of more recent legis-lation in many cases appear to havepurposefully blurred or actuallycrossed the line between a right towithdraw and a right to obstruct.One subtle example of this was aprovision included in 1997 legisla-tion that created national standardsfor Medicaid managed care, includ-ing the standard that plans could not“gag” providers from telling Medicaidpatients about treatment options notcovered by the plan. Yet, Congressalso allowed plans to refuse to covercounseling and referral activities towhich they object on religious ormoral grounds, creating a financialbarrier to obtaining informed con-sent and ensuring access to care.

Another obstructionist provision,named after its sponsor, Rep. DaveWeldon (R-FL), was passed in 2004as part of an annual appropriationslaw. It forbids federal, state and localgovernments from requiring any

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WHAT LEADING PROFESSIONAL ASSOCIATIONSSAY ABOUT PROVIDERS’ REFUSAL

“The physician may not discontinue treatment of a patient as long as further treatment is medicallyindicated, without giving the patient reasonable assistance and sufficient opportunity to make alter-native arrangements for care.”—World Medical Association, Declaration on the Rights of the Patient

“The patient’s right of self-decision can be effectively exercised only if the patient possesses enough in-formation to enable an intelligent choice.…The physician has an ethical obligation to help the patientmake choices from among the therapeutic alternatives consistent with good medical practice.”—American Medical Association, position statement on informed consent

“Where a particular treatment, intervention, activity, or practice is morally objectionable to thenurse…the nurse is justified in refusing to participate on moral grounds.…The nurse is obliged toprovide for the patient’s safety, to avoid patient abandonment, and to withdraw only when assuredthat alternative sources of nursing care are available to the patient.”—American Nurses Association,Code of Ethics

“A [physician assistant] has an ethical duty to offer each patient the full range of information on rele-vant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from of-fering the full range of treatments available or care the patient desires, the PA has an ethical duty torefer an established patient to another qualified provider. PAs are obligated to care for patients inemergency situations and to responsibly transfer established patients if they cannot care for them.”—American Academy of Physician Assistants, Guidelines for Ethical Conduct for the Physician AssistantProfession

“[P]harmacists [should] be allowed to excuse themselves from dispensing situations which they findmorally objectionable, but that removal from participation must be accompanied by responsibility tothe patient and performance of certain professional duties which accompany the refusal.…ensuringthat the patient will be referred to another pharmacist or be channeled into another available healthsystem.…Pharmacists and their employers will need to develop processes that support the decision ofthe individual pharmacist while still providing the appropriate services the patient seeks.”—AmericanPharmacists Association, 1997–98 policy committee report on pharmacist conscience clause

“Pediatricians should not impose their values on the decision-making process and should be preparedto support the adolescent in her decision or refer her to a physician who can.…Should a pediatricianchoose not to counsel the adolescent patient about sexual matters such as pregnancy and abortion, thepatient should be referred to other experienced professionals.”—American Academy of Pediatrics,position statement on counseling the adolescent about pregnancy options

“Nurses have the right, under responsible procedures, to refuse to assist in the performance of abor-tion and/or sterilization procedures.…Nurses have the professional responsibility to provide highquality, impartial nursing care to all patients in emergency situations.…to provide nonjudgmentalnursing care to all patients, either directly or through appropriate and timely referral.…[and] to in-form their employers, at the time of employment, of any attitudes and beliefs that may interfere withessential job functions.”—Association of Women’s Health, Obstetric and Neonatal Nurses, position statementon nurses’ rights and responsibilities related to abortion and sterilization

individual or institutional provideror payer to perform, provide, referfor, or pay for an abortion. This goeswell beyond the Church Amendmentand violates several of the principlesendorsed by the AMA, ANA and oth-ers. The National Family Planningand Reproductive Health Associationhas filed a lawsuit, arguing that theWeldon Amendment conflicts withthe requirement that clinics receiv-ing federal Title X family planningfunds provide abortion referralswhen requested subsequent tonondirective counseling aboutpatients’ full range of pregnancyoptions. California’s attorney generalhas also sued, asserting that the newlaw would force the state to eithersacrifice billions of dollars of federalaid or else ignore several of thestate’s own laws, including thoserequiring the provision of abortionservices in emergency circum-stances; in June, a federal judgerejected the U.S. government’smotion to dismiss that lawsuit.

A law passed in Mississippi in 2004may be the best example of theexpansive new breed of refusalclause. It allows almost anyone con-nected with the health care indus-try—from doctors, nurses andpharmacists to the clerical staff ofhospitals, nursing homes and drugstores—to refuse to participate orassist in any type of health care ser-vice, including referral and counsel-ing, without liability or consequence.In the process, it violates every oneof the obligations to patients andemployers listed above around infor-mation, referral, emergencies, noticeand the like.

Finding Balance

A CBS News/New York Times poll inNovember 2004 found that nearlyeight in 10 Americans believe thatpharmacists should be required tofill prescriptions for birth control,even when they have religious objec-tions. A poll of U.S. doctors in Juneyielded similar findings. Yet notably,

much of the public debate aroundemergency contraception, and con-traception more generally, has cen-tered not simply on pharmacists’refusal to fill a prescription. Rather,many observers have focused oncases where pharmacists haverefused to transfer a prescription orrefer a client to another pharmacistand where they have made often-times hostile attempts to dissuadewomen from using the product.

Some advocates for expansive refusalrights have argued that such actionsare justified and should be protected.They assert, for example, that apharmacist who refers a woman tosomeone else to fill her prescriptionfor contraception is just as guilty asif the pharmacist filled the prescrip-tion himself. As one anticontracep-tion pharmacist put it in aninterview with the Washington Post,“That’s like saying, ‘I don’t kill peo-ple myself but let me tell you aboutthe guy down the street who does.’”These arguments have been madefor decades, yet the fact remains thatthey are in direct conflict with theethical guidelines that govern thehealth care professions and thatmake clear that abandoning apatient in this way is unacceptable.

Such extremist behavior appears tobe fueling a backlash. Policies adopt-ed this year in Illinois and Nevadaand introduced in at least five otherstates and in Congress would ensurethat patients have access to legallyprescribed medications, often byrequiring a pharmacy to meet thisneed even if an individual pharma-cist it employs refuses (see relatedstory, page 10). Several of the pro-posals specifically prohibit pharma-cists from refusing to refer ortransfer a prescription and forbidverbal abuse and threats to breachpatients’ confidentiality. The AMAresponded to the pharmacist contro-versy in June by adopting a resolu-tion supporting legislation to ensurethat pharmacists and pharmacieseither fill valid prescriptions or “pro-

vide immediate referral to an appro-priate alternative dispensing phar-macy without interference.”

Some reproductive rights advocateshave raised practical questions aboutwhether it is possible to accommo-date pharmacist refusal and stillguarantee women’s access to thecontraceptives to which they areentitled. It sounds reasonable that apharmacy ensure that every pre-scription is filled, even if an individ-ual pharmacist refuses, but this canbe difficult in pharmacies whereonly one pharmacist is on duty at atime. Perhaps requiring referral toanother pharmacy is an answer, butis that pharmacy close enough?Does it accept the customer’s insur-ance? Does it have the drug instock? Will the pharmacist thererefuse as well? And what impact willthat have on the original pharmacyin terms of customers lost?

Such concerns have led to evenmore creative proposals. The AMA,for example, has called for legisla-tion allowing doctors to dispensemedication when no pharmacistwithin 30 miles is “able and willing”to do the job. Lawmakers, likewise,have addressed some of these detailsin crafting their proposals. Ultimate-ly, no policy may be able to addressevery contingency, however. In suchcases, professional standards arethere to provide guidance, and toremind everyone that responsibilityto the patient must always be thetop priority and that a right to with-draw must never be turned into aright to obstruct.

This article was supported in part by grantsfrom the Prospect Hill Foundation and theCompton Foundation. The conclusions andopinions expressed in this article, however,are those of the author and the GuttmacherInstitute.

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