Consensus Grows that Patients’ Needs Ultimately Outweigh Providers’ Right to Refuse Services

Every Effort Should Be Made to Accommodate Providers’ Religious Beliefs, But Not at Expense of Patients

A consensus that the patient’s well-being is paramount is emerging in the debate over an appropriate balance between patients’ access to care and health care professionals’ right to refuse services based on their religious or moral beliefs, according to a new Guttmacher Institute policy analysis. In a shift away from a near-exclusive focus on establishing a provider’s right of refusal, this growing consensus is reflected in current trends in policymaking, the guidelines of health care associations and public opinion.

"It appears that Americans’ fundamental practicality is reshaping the long-running debate over refusal," says Adam Sonfield, senior public policy associate at the Guttmacher Institute and author of the new analysis. "At issue are cases where, for instance, patients have been unable to fill prescriptions for contraceptives because their pharmacist objects to birth control. Americans have traditionally been supportive of attempts to accommodate the religious and moral beliefs of individual health care professionals. There is now rising agreement, however, that in striking the appropriate balance in cases of conflict, the patient’s needs must prevail."

According to the analysis, the most extreme advocates of refusal have had only three real victories over the course of this decade in Congress and the state legislatures. Instead, the legislation and regulations adopted have moderated these demands and established at least some right for patients to receive care. Since 2004, seven new states, for a total of 27, have required insurers that cover prescription drugs in general to provide coverage of the full range of contraceptive drugs and devices. Eight new states, for a total of 16, have required hospital emergency departments to provide information about emergency contraception to sexual assault victims, dispense the drug upon request or both. And four states have taken steps to affirm that pharmacies must dispense lawfully prescribed contraceptives and other drugs, regardless of the beliefs of individual employees.

"Historically, the issue of refusal had been framed most consistently and assertively by proponents of refusal, who have promoted it as an issue of individual, generally religious, rights and discrimination," says Sonfield. "That frame has always been something of a distortion. As a matter of law, there is no ‘right’ in the United States to be employed in a given profession any more than there is, by and large, a right to health care. Still, what appears to be resonating among Americans is a solution rooted in essentially acknowledging those rights as asserted and striking a balance between them."

Collectively, health care professionals have endorsed this solution in the context of professional guidelines and standards. In November 2007, the committee on ethics of the American College of Obstetricians and Gynecologists asserted that a right to refuse does exist but must be balanced with physicians’ other values and duties. The committee laid out four criteria for gauging this balance: the degree to which refusal imposes the provider’s beliefs on patients’ autonomy; impacts patients’ health and perception of well-being; is based on proper understanding of scientific evidence; and results, intentionally or not, in discrimination and inequality.

The American Medical Association and the American Public Health Association have weighed in on the subject in the past several years, as well, recommending steps to ensure that patients can have prescriptions filled with a minimum of difficulty or interference.

"Getting this practicality written appropriately into public policy is by no means a simple proposition," warns Sonfield. "To ensure that it happens, advocates of patients’ health and rights will need to sound that message clearly, consistently and forcefully."

Click here to read "Provider Refusal and Access to Reproductive Health Services: Approaching a New Balance," by Adam Sonfield, in the Spring 2008 issue of the Guttmacher Policy Review.

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Overview of state policies on refusing to provide health services

Overview of state policies on emergency contraception

Overview of state policies on insurance coverage for contraceptives

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