ACOG, under fire, vows to review conscience opinion
Criticism comes from HHS, ACOG fellows
In the wake of complaints from doctors who said a November 2007 opinion from the American College of Obstetricians and Gynecologists (ACOG) threatened their rights of conscience, ACOG has issued a statement insisting it "affirms the importance of conscience in shaping ethical professional conduct" and will re-examine the controversial opinion, which states that physicians who oppose sterilization and abortion are compelled to refer patients to doctors who don't object to the procedures.
Physicians opposed to abortion were especially incensed by the opinion, which some said threatened their ability to practice. Health and Human Services Secretary Michael Leavitt entered the fray in March, releasing a letter to ACOG and the American Board of Obstetrics and Gynecology (ABOG) in which he expressed concern that the policy endangered physicians' conscience rights.
ACOG: Physician conscience not threatened
ACOG Opinion 385 was released in November as a position paper that proposes a definition of conscience and describes how ACOG member physicians should weigh their claims of conscience against provision of reproductive medicine. ACOG describes the paper as "a framework for defining the ethically appropriate limits of conscientious refusal in reproductive health contexts."1
However, the American Association of ProLife Obstetricians and Gynecologists (AAPOG) and the Christian Medical Association (CMA), along with some 20 other health, religious, and conservative organizations, countered with objections that the opinion was ACOG's attempt to "shut down" the convictions of doctors who are opposed to abortion and sterilization.
The opinion, drafted by the ACOG ethics committee, says physicians who have religious or moral objections to practices such as abortion, sterilization, or prescribing contraceptives are not ethically obligated to provide those services, but should take steps to ensure patients can get those services elsewhere.
When crises of conscience arise, the association instructs physicians to consider four criteria:
- the degree to which the conscientious refusal creates an imposition on the patient;
- the effect the refusal can have on patient health;
- scientific integrity;
- potential for discrimination.
ACOG recommends physicians with strong moral objections to abortion, sterilization, emergency contraception, and other reproductive therapies:
- make patient well-being paramount;
- impart unbiased and accurate information for patients to use in making informed decisions;
- disclose, accurately and ahead of time, their personal moral commitments regarding the objectionable practice;
- refer patients to other providers when they are unable to provide "the standard reproductive services" requested by patients;
- in an emergency, provide medically indicated care regardless of personal moral objections;
- practice in proximity to physicians who do not share their moral objections, or otherwise ensure a referral process that allows patients to receive the care they request.
Anti-abortion physicians — and others who don't object to the practices but feel the opinion impinges on conscience rights — have complained that requiring doctors to refer patients against their conscience and even locate their practices in proximity to physicians who don't share their moral beliefs in order to facilitate those referrals threatens their ability to practice in accordance with their personal ethical convictions.
In his letter, Leavitt expressed concern that the opinion threatens not only conscience rights, but possibly professional certification; Leavitt wrote that decertification of doctors unwilling to perform abortions could lead to legal woes for health organizations that require ABOG certification, because federal law prohibits health organizations from receiving federal funds if they discriminate against doctors who refuse to perform or refer for abortions.
In a statement released following Leavitt's letter, ACOG President Kenneth Noller asserts that a doctor's ABOG certification is not jeopardized by non-adherence to Opinion 385; however, a January ABOG bulletin indicates that a physician's board certification could be revoked for "violation of ABOG or ACOG rules and/or ethics principles."
Noting the mixed interpretations of the meaning and impact of Opinion 385, as well as the reaction from Leavitt and member physicians, Noller released the following statement in March:
"We want to be clear the Opinion does not compel any fellow to perform any procedure which he or she finds to be in conflict with his or her conscience and affirms the importance of conscience in shaping ethical professional conduct. While this opinion attempted to provide guidance for balancing the critical role of conscience with a woman's right to access reproductive medicine, the executive committee has noted the uncertain and mixed interpretation of this opinion. Thus, the executive committee has instructed the committee on ethics to hold a special meeting as soon as possible to reeavaluate ACOG Committee Opinion #385."2
Revoke or keep Opinion 385?
Gene Rudd, MD, an obstetrician and gynecologist who serves as executive vice president of the Christian Medical and Dental Association, based in Bristol, TN, told Medical Ethics Advisor in January that the ACOG position led him to resign his ACOG membership of more than 25 years.
"My conscience can no longer support their lack of conscience," says Rudd. He stated after the ACOG announcement that while he was pleased the college would revisit Opinion 385, revocation of the opinion paper would be the only satisfactory outcome.
However, groups such as New York City-based Physicians for Reproductive Choice and Health (PRCH) are just as adamant that the opinion remain intact and in force.
"As physicians, our primary duty is to protect our patients' health," notes Wendy Chavkin, MD, immediate past board chair of PRCH. "While individual doctors have every right not to provide care that conflicts with their religious beliefs, they must offer complete and accurate information about abortion and contraception to their patients, including referral to another doctor or facility. Physicians do not have the right to impose their personal moral or religious beliefs on their patients, who may not share them."
References
- ACOG Committee Opinion, No. 385. The Limits of Conscientious Refusal in Reproductive Medicine. Obstet Gynecol 2007;110:1,203-1,208.
- ACOG's response to Fellows regarding Committee Opinion #385, "The Limits of Conscientious Refusal in Reproductive Medicine." March 26, 2008; available online at www.acog.org.
Sources
For more information, contact:
- Gene Rudd, MD, executive vice president, Christian Medical and Dental Association, Bristol, TN. Phone: (423) 844-1000.
- Wendy Chavkin, MD, immediate past board chair, Physicians for Reproductive Choice and Health, New York, NY. Phone: (646) 366-1890.
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