President Trump recently announced a new rule, issued by the Department of Health and Human Services, that allows doctors, hospitals, insurers and other providers of health care to refuse to deliver or fund services like abortion, assisted suicide or procedures for transgender patients that they say violate their religious views.
The action has been criticized by Democrats and civil liberties groups, with some arguing that it serves as a pretext for discrimination against marginalized groups and threatens to substitute religious views for sound medical advice. But it also invites a larger question: What should doctors do when a patient’s request runs counter to their moral convictions? In medicine we often talk about a patient’s right to refuse treatment. But what about a doctor’s right to deny it?
Such questions have not been definitively resolved by courts or legislatures. The American Medical Association, for its part, is somewhat ambivalent on the issue. The organization’s code of ethics states that physicians have a responsibility “to place patients’ welfare above their own self-interest.” But it also recognizes that doctors are individuals with the right to free choice, stating that “physicians should have considerable latitude to practice in accord with well-considered, deeply held beliefs that are central to their self-identities.” At the same time, that freedom, the code says, “is not unlimited.”
A consensus exists among legal and bioethics experts that doctors can refuse to provide treatment in certain situations. For example, courts have ruled that doctors may refuse to treat violent or intransigent patients as long as they give proper notice so that those patients can find alternative care. Forcing doctors to treat such patients, courts have said, would violate the 13th Amendment’s prohibition on involuntary servitude.
Doctors may also refuse to provide treatment if it conflicts with good medical practice. Physicians in intensive-care units, for example, routinely limit treatment they believe will provide no benefit, especially in cases of terminal illness. I once took care of a man in his 50s who had metastatic cancer and respiratory failure requiring a ventilator. His family refused to turn off the machine and let him die, choosing instead to escalate treatment. However, life support in his case was futile. After consulting with the hospital’s ethics committee, my colleagues and I told the family members that we would no longer obey their wishes. We gave them the option of transferring the patient to another hospital. They didn’t want to do that; treatment was scaled back and the man died a few days later.
But refusing to treat a patient on the basis of conscience, which the Trump administration is defending, is more problematic. Federal legislation already permits doctors to opt out of care that is incompatible with their religious or moral beliefs. Gynecologists, for example, may refuse to perform abortions on those grounds.
However, the American Medical Association has stated that such rights should not “unduly burden” patients or discriminate against their civil liberties. And because doctors control the provision of medical care, this can easily happen. Conscientious objection by doctors necessarily limits a patient’s own right to self-determination. Of course, patients can be directed to find a doctor to do their bidding, but this can lead to potentially dangerous delays, especially in resource-poor areas.
Conscientious objection can also promote outright discrimination. Christian medical associations, for example, have argued that providing treatment to transgender individuals can constitute “cooperation with evil.” In some cases conscientious objection may be motivated by rank prejudice as opposed to religious conscience — a distinction that can be hard to parse in practice.
Doctors have an obligation to adhere to the norms of their profession. In my view, as long as treatments are safe and sanctioned by medical organizations, doctors should have limited leeway in refusing to provide them. Patients’ needs should come first. At the very least, patients whose medical needs violate a doctor’s deeply considered beliefs should receive a timely referral to an alternative provider. And to avoid such conflicts, medical students who foresee problems of conscience should steer clear of certain fields, such as obstetrics-gynecology, when making career choices. Broad conscientious objection of the sort the Trump administration is defending could lead to chaos in health care.
Doctors are asked all the time to sacrifice personal beliefs in the service of professional ideals. I am reminded of a patient I once took care of who had AIDS and an irremediable intravenous drug habit. He needed a new heart valve because his current valve — itself a replacement for a previously infected valve — had gotten infected from shooting heroin. Surgeons at my hospital balked, saying that they would not operate on a patient who was almost certainly going to continue to use drugs and risk future infections. The case went to the hospital ethics committee. “I personally might not want to operate,” a physician told the surgical team. “But then, I did not choose to be a surgeon.”
The patient got his operation the following week.
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