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The physician assistant’s professional obligations and the values of faith

F.J. Gianola, PA, DFAAPA

F.J. Gianola is the department editor for PA Quandaries and is on the faculty of the MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine, Seattle. He has indicated no relationships to disclose relating to the content of this article.

CASE

Guadalupe Benitez had been with her same-sex partner for many years. They wanted to start a family, but Ms. Benitez had fertility problems due to polycystic ovarian syndrome. Her primary care physician referred her to an infertility clinic, which had the exclusive contract to provide infertility services for members of her insurance plan. At the clinic, Ms Benitez was told that if pregnancy was not achieved through intravaginal self-insemination, her physician would not perform intrauterine insemination (IUI) because he had religious objections to providing IUI to a woman in a same-sex relationship. However, Ms. Benitez was assured that another physician at the clinic would perform the IUI if needed. Ms. Benitez was troubled about what she heard but decided that her insurance plan gave her no choice but to accept it. Over the next 11 months, she underwent fertility treatment but was unable to achieve pregnancy.

When Ms. Benitez’s physician went on vacation, the covering physician refused to renew her fertility medication. He also refused to perform IUI. He told Ms. Benitez that a majority of the staff at the clinic shared his objection to providing IUI to women who were in same-sex relationships. He recommended that she go elsewhere for treatment.

THE ETHICAL QUANDARY

Can the religious conviction of a physician (or physician assistant) be a legitimate basis to refuse to provide a therapy for a patient?

DISCUSSION

Medical indications (beneficence and nonmaleficence) Ms. Benitez had polycystic ovarian syndrome, a condition affecting 5% to 8% of reproductive-age women that often leads to infertility.¹ Therapies are available, and IUI is not an uncommon procedure offered to such women.

Patient preference (autonomy) After considerable research into her condition and discussions with her partner and primary care provider, Ms. Benitez wanted therapies, including IUI, that would produce a pregnancy.

Quality of life (beneficence, nonmaleficence, and autonomy) Ms. Benitez and her partner had been planning for a family with children. Not having children would decrease their quality of life.

Contextual features (justice) This type of case presents the physician assistant with at least three major considerations: the faith values of the PA; the obligations of the PA; and the moral agency of the patient.

With respect to the faith values of the PA, Pellegrino has identified a number of considerations when a situation arises of objections to providing a medical service that is in conflict with faith values of the provider.² Some of these include why the objections due to conscience are important, the components of the provider’s conscience, and whether objections due to conscience are important in the 21st century. Pellegrino speculates that “… for all religious oriented physicians the question must be addressed—is it possible to maintain moral integrity and remain an active physician is a secular world?”²

Do good and not evil is at the core of our moral decisions. The question for us as PAs is whether we are doing “good” for our patients or “good” for ourselves. We have our professional principles and obligations, and we have our personal principles and obligations. Honor requires protection of both. The question here is how, when, or whether professional obligation takes precedent.

Collett has accepted as true that “Now is the time for all health care providers to act in accordance with their conscience and consider their commitments. Because,” she says, “there are interventions within medicine that are legally—but not morally—permissible, health care providers must ‘choose this day whom [they] will serve.’”³

Wicclair notes that providers with a conscientious objection often cite autonomy to justify their objection. He concludes that autonomy is an important ethical foundation for a patient’s refusal of treatment. However, it is not reciprocal for providers. If the provider refuses to treat a patient because doing so would violate the provider’s autonomy and refers the patient to another provider who provides the service requested, the referring provider’s conscience would be respected but not his autonomy, because the patient was not treated in the manner the provider reasoned appropriate. However, what if the PA believes her moral integrity is compromised by the referral, even though the procedure the patient requested is the standard of care? Wicclair maintains that

Appeals to conscience can have significant moral weight even when [physician assistants] have conscience-based objections to practices which are endorsed by established norms of medical ethics. However, since values and interests, such as patient autonomy, dignity, and well being, are also at stake, it is unwarranted to give [physician assistants] more or less blanket permission to withdraw from patient care in such cases. Instead, there needs to be more nuanced understanding and analysis of the relevant moral interests and values.⁴

Curlin and colleagues found that 63% of 1,144 physicians responding to their survey thought it was ethical to explain their moral objections to patients.⁵ However, 86% thought all therapeutic options should be presented to the patient, and 71% believed that referring the patient to another provider who did not have objections to a requested procedure was required.⁵

Franke has an insight worth considering, which is that “values may be subject to change over time.” Perhaps, she says, “it is more the degree of intensity accorded certain values that change over time rather than the values themselves.”⁶

When considering the obligations of the PA, we must ask whether physicians and PAs have a primary obligation to a society that has given them a monopoly to offer medical services, a considerable status, and sizeable earnings. Is denying a service to a patient when the provider has the knowledge and skills to provide it an abuse of the privileges bestowed by society?

The Guidelines for Ethical Conduct for the Physician Assistant Profession state that “physician assistants should not discriminate against classes or categories of patients in the delivery of needed health care….”⁷ The foundation of these guidelines rests on the profession’s responsibility to the general public. In a similar manner, The Ethics Committee of the American Society for Reproductive Medicine concluded that unmarried persons and gays and lesbians have interests in having and rearing children; there is no persuasive evidence that children raised by single parents or by gays and lesbians are harmed or disadvantaged by that fact alone; and programs should treat all requests for assisted reproduction equally without regard to marital status or sexual orientation.⁸

Regarding the moral agency of the patient, we find that the prime participants are women in most reproduction cases involving ethical dilemmas. What is the status of the moral agency of a woman? Agency is the capacity or condition exerting power, and morality refers to what is right and wrong in behavior. When the issues of abortion, contraception, and fertility are addressed and the state or a faith value intervene directly or via a provider, is the patient’s moral agency diminished? If it is, what is the rationale for negating the woman’s autonomy? Is there a parallel situation for a man?

Some professional societies and members of the medical community have suggested that those with faith-based concerns of conscience choose a specialty of medicine where personal faith values will not collide with patient care. Others have been even more strident, recommending that those with values of faith that would hinder the provision of full health services to their patients consider working in another profession.

The Bush Administration disagrees with these suggestions. The Executive Branch has put forth potential regulations that “require all recipients of aid under federal health programs to certify that they will not refuse to hire nurses and other providers who object to abortion and even certain types of birth control.”⁹

The struggle between religion and science will continue. If one finds oneself within the maelstrom of any of theses issues, Franke provides an introspective approach. When caring for patients with whom you have a moral disagreement, “…compassion, and empathy for your patient and her situation, are not excluded when the physician assistant and patient’s values, religious or secular, differ.”⁶ Most of us entered the field of medicine to care for the ill, injured, and suffering. In many instances, our values of faith encouraged or at least complemented this decision. When our values of faith are challenged by the choices made by our patients, our colleagues and our professional associations can provide helpful direction and apposite support. JAAPA

REFERENCES

	1.	Franks S. Polycystic ovary syndrome. N Engl J Med. 1995; 333(13):853–861.
	2.	Pellegrino ED. The physician’s conscience, conscience clauses, and religious belief: a Catholic perspective. Fordham Urban Law J. 2002;30(1):221-244.
	3.	Collett TS. Protecting the health care provider’s right of conscience. The Center for Bioethics & Human Dignity Web site. 2004. http://www.cbhd.org/resources/healthcare/collett_2004-04-27. Accessed September 9, 2008.
	4.	Wicclair MR. Conscientious objection in medicine. Bioethics. 2000;14(3):205-227.
	5.	Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007;356(6):593-600.
	6.	Franke D. Religious ethical considerations. In: Cassidy B, Blessing JD, eds. Ethics and Professionalism: A Guide for the Physician Assistant. Philadelphia, PA: FA Davis; 2008:127-139.
	7.	The Guidelines for Ethical Conduct for the Physician Assistant Profession. Alexandria, VA: American Academy of Physician Assistants; adopted 2000, amended 2004, 2006, 2007, and 2008. http://www.aapa.org/manual/22-EthicalConduct.pdf. Accessed September 9, 2008.
	8.	Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment by gays, lesbians, and unmarried persons. Fertil Steril. 2006;86(5):1333-1335.
	9.	Pear R. Abortion proposal sets condition on aid. New York Times. July 15, 2008. http://www.nytimes.com/2008/07/15/washington/15rule.html?_r=1&scp=1&sq=Abortion%20proposal%20sets%20condition%20on%20aid&st=cse&oref=slogin. Accessed September 9, 2008.