In health care, the ideological quagmire [7] surrounding conscience gets deeper with each forward step. Unprecedented changes in medicine are creating a crisis in conscience at many levels, both in terms of technological and scientific advances, and in terms of the ethical pressure placed on a system that is failing economically [8] at every level.
Today's health care system makes a clear conscience a challenge for many, no matter what you believe.
So when it comes to conscience clauses [9], I have to ask, should this really be the issue that it has become?
We could explore nearly all of the issues with conscience clauses in America by looking at the reproductive health care field. If a pharmacist doesn't choose to prescribe emergency contraception, the birth control pill, or display condoms, I –- and almost all Americans -– have no problem with her personal decision to do that, so long as someone else in the pharmacy will unlock the condoms, fill a prescription and help a woman out who might be trying to avoid an unintended pregnancy and possible abortion. The sensible, mainstream feeling on this is that accommodating for human vulnerability seems not only wise, but compassionate -- a combination Americans hope for in all of our health care professionals. Conscience should be respected in this case, but so should the needs, and conscience decisions, of a person seeking legal healthcare.
But are these situations we’re seeing these days really about a “right of conscience?” If pharmacists find themselves in the position above, or if doctors don't want to perform abortions or sterilizations, great. We can respect that. But can they offer respect in return? The same people who claim or support “right of conscience” in these cases are often the same people who protest, sometimes violently [10], outside offices of those who are willing to provide abortions. There is serious hypocrisy here, and I question the claim that these people are really after freedom of conscience. It seems more likely that they’re trying to force their beliefs on others.
In Oregon, pharmacists have not only refused to fill contraception prescriptions but have confiscated the prescription [11] form, making it difficult to simply go to another pharmacist. Is that a respectable exercise of conscience in a pluralistic democracy, or is it purely an infringement on another person’s rights and property?
At the other end of human life, Oregon's Death with Dignity Law [12] has a conscience clause written directly into the statute [13] approved twice by that state's voters that offers lessons as this debate within reproductive health continues.
The principle drafter of the law, Portland attorney Eli Stutsman [14], understood the necessity of allowing medical professionals the option of not participating in the prescribing process. The personal decision of a terminally-ill patient facing intolerable suffering, and requesting a peaceful, dignified death at a time and place of their choosing, surrounded by their loved ones, should not compel a doctor who does not believe as the patient does to write the prescription. Allowing doctors who could not in good conscience participate was logical and helped establish what has become a triumph of reasoned public policy on a once controversial and cutting edge issue. The law did not force anything on anyone. Rather, it created neutral space for patients and professionals whose values allowed this option, to come together, each with their own beliefs, and provided stringent safeguards to protect all parties.
Two things have happened as a result of that clause. Ideological opponents have attempted to stigmatize [15] patients and doctors who do participate, a page taken from the far-right playbook on many issues. The stigmatizing has failed to take root and only served to push those opposed further outside that state's overwhelming mainstream of support for the Death with Dignity law. A more diverse set of doctors [16] participate each year.
The other thing that has happened is that patients, perfectly healthy with no signs of any terminal illness, are having serious "what if" conversations with their doctors. Many are changing doctors based on the responses they receive. Patients are becoming better consumers of health care, and are establishing relationships with medical professionals they are in agreement with.
It is curious that some doctors, whose conscience does not allow them to write the prescription under the Death with Dignity law, do not make that known to their terminally ill patients until the request is made, or delay transferring patient records when that patient decides to find a doctor that will help them. In good conscience, doctors or pharmacists who will not offer legal, safe, and accepted practices, should make that clear so their patients don’t find themselves vulnerable and abandoned simply because they believe differently than their health care provider.
What about when institutional consciences are involved?
In rural Oregon and much of the West, Catholic Healthcare West is the dominant health provider, forcing many in rural areas who do not subscribe to their religious beliefs to drive hours away from home in their time of greatest need.
Lack of contraception services or counseling, or honest conversation with medical professionals about reproductive health and sexuality education, or personal end of life decisions, can be difficult to come by in many parts of rural America because institutions place their beliefs [17] above those of the people they claim to serve.
Some of these make for mere inconvenience for the patient, but others are genuinely crisis situations. At that point, are those professionals stepping beyond the exercise of their conscience? Or at least, the exercise of their conscience in light of their commitment to serve the public in a diverse society?
Because of these issues, people are increasingly taking responsibility for their health care decisions and aligning themselves with professionals who have similar values and will allow them to fully participate in their health care decision-making. This is good for the patient, and good for the doctors.
The truth is that for many ideological extremists it is not simply about their individual conscience, but about imposing their values on everyone else. This “exercise of conscience” may make sense to them in a vacuum, but it has concrete detrimental effects in society when people cannot access safe and legal healthcare. Like so much of their rhetoric, the notion of a conscience clause is a tactic to mask their real agenda: making medical services they don't believe in as hard to obtain as possible (if they can’t succeed in making them illegal).
The American people support the right of conscience, exercised reasonably and with respect to the law and other individuals. There is a safe middle ground there for both sides to pursue in this debate.
Ian contributed to this piece.