Carolyn McLeod claims that it is wrong for physicians who conscientiously refuse to prescribe birth control to prioritize their conscience over patient care.
Recently, a woman went to a walk-in clinic in Ottawa to request birth control and was handed the following letter:
Please be advised that because of reasons of my own medical judgment as well as professional ethical concerns and religious values, I only provide one form of birth control, Natural Family Planning. In addition, I do not refer for vasectomies, abortions nor prescribe the morning after pill or any artificial contraception. If you are interested in the latter, please be aware that you may approach your own family doctor or request to be seen by another physician….
With deepest respect, Edmond Kyrillos, B. Eng., MD, CCFP Ottawa Ontario
Unsurprisingly, the form of birth control the woman wanted was not natural family planning. She reported feeling embarrassed and almost ashamed by her request when she had to walk out of the clinic, letter in hand, in front of a group of people (here). Had a different family physician been working at the clinic that day, she might have had the same experience; two other physicians who practice there give similar letters to their patients (here and here).
In response to this case, Dr. Jeff Blackmer—Executive Director of the Office of Ethics of the Canadian Medical Association— was quoted in the media as saying, “We don’t expect [doctors] to check their morals at the door; we recognize they will continue to hold personal views.” This statement erroneously suggests that there is nothing wrong with Kyrillos’s letter. On the contrary, the content of the letter and more generally the manner in which Kyrillos and his colleagues practice medicine are deeply problematic.
First, Kyrillos claims to have been acting not simply on his “morals” but also on his “medical judgment.” He is unclear about what this judgment is, but one could easily interpret him as saying that there are medical reasons to prefer natural over “artificial” family planning. Unless the CMA agrees with this statement, Blackmer should have questioned it. He should have objected to the letter on the grounds that Kyrillos showed a lack of professionalism by suggesting (albeit vaguely) that expert opinion favours natural family planning over other forms of birth control.
Second, Kyrillos should not have acted on his moral and religious values to the extent that he did. For example, in refusing to give referrals for legal and professionally accepted services (“standard” services), including abortions, he arguably violated the right of patients to access these services. Now some will object that individual physicians are not required to offer care to everyone; indeed, they are free to turn down potential patients with whom they are uncomfortable working for moral or religious reasons. However, to the extent that physicians have this freedom, it is not absolute. For if it were absolute, then a Muslim physician could refuse to accept female patients, a Catholic physician could deny care to women who have had previous abortions, a Jehovah’s Witness physician could refuse to order blood transfusions, etc.
Third, the manner in which Kyrillos acted on his moral and religious beliefs was problematic. Physicians who refuse patient requests for standard services on grounds of conscience should not leave patients feeling as though they are not entitled to these services, or as though they have done something wrong. Kyrillos was not able to avoid this consequence, and show the “deepest respect” he claimed to have for his patients, because of the method he chose to convey his objection (i.e., an impersonal letter). A more professional response would have been for Kyrillos to meet with the patient, explain that he had a moral objection, acknowledge that the patient’s request was nonetheless legitimate, and then refer the patient to a physician who would provide the necessary care. Although l worry that in some cases, a face-to-face meeting will cause more harm than good, in principle I believe that this is the morally mature option for conscientious objectors to take.
To return to Blackmer, instead of saying that physicians “do not have to check their morals at the door,” he should have said that there are times when physicians have to do just that. They cannot act on moral beliefs that prevent them from providing referrals for standard services or from assuring patients that they are not bad people if they ask for such care. In addition, physicians cannot mislead patients into thinking that their personal moral beliefs have the imprimatur of medical science when they do not.
Carolyn McLeod is Associate Professor of Philosophy at Western University and Principal Investigator on the CIHR funded project, Let Conscience Be Their Guide? Conscientious Refusals in Reproductive Health Care. In 2014-15, she is Visiting Professor at the Centre for Ethics at the University of Toronto.