Medical rights of conscience

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Physician rights of conscience provisions were codified into US law in the 1970s when the “Church Amendments” were added to Title 42 of the Public Health and Welfare Statute (1).  Section 245 of the Public Health Service Act of 1996 prohibited the federal government or any state or local government that received federal funding from discriminating against a healthcare professional or institution because the healthcare professional or institution: 

1) Refuses to undergo training in the performance of an induced abortion, requires such training, or provide referrals for such training, 

2) Refuses to make arrangements for such activities, or 

3) Attends (or did attend) a post-graduate physician training program that does not (or did not) perform induced abortions or require, provide, or refer for training in the performance of induced abortions, or make arrangements for the provision of such training (2).  

The Weldon amendments passed as part of the Health and Human Services appropriations and have been adopted in each subsequent HHS appropriation act since 2005 provide that, “None of the funds made available in this Act may be made available to a Federal agency or program, or to a State or local government if such agency, program, or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions (3)."  In addition, The Affordable Care Act includes conscience protections for abortion and assisted suicide (4,5).

Despite these legal protections, physicians’ freedom of conscience is under attack by those who believe that certain procedures and interventions are part of healthcare.  We believe that a physician’s freedom of conscience supersedes controversial laws when in good faith the physician believes he or she cannot participate in acts such as abortion, assisted suicided or procedures that alter a patient’s normal anatomy for subjective reasons. Expecting physicians to violate their fundamental moral commitments jeopardizes the physician-patient relationship, contributes to moral injury and burnout of the clinician, and should not be tolerated.  Some medical schools and residency training programs have abortion and physician-assisted suicide training structured as “opt-out” educational programs, rather than maintaining “opt-in” options, leading to trainee coercion, intimidation, and discrimination.

The Hippocratic Oath declares: “I will not help a patient to commit suicide, nor will I suggest such a course. Similarly, I will not help a woman obtain an elective abortion. In purity and holiness, I will maintain the utmost respect for human life, carefully guarding my role as a healer.”  The fundamental principle of the Hippocratic Ethic is to first, do no harm. We must recognize that the medical community sometimes has different opinions about what constitutes best practices, and harm, to the patient. When physicians have different interpretations of scientific studies and treatment options, we must recognize that well-reasoned and researched plans contribute to physician convictions which should be respected. Healthcare professionals striving to act in the best interest of the patient while refusing to participate in a controversial practice are not abandoning their patients or failing to fulfill their duty to care. 

The American College of Family Medicine affirms the following:

1. Physicians should not be coerced, intimidated, nor forced to provide services or refer directly for services which violate their philosophical beliefs or moral convictions.
2. Educational institutions, educators, and trainees should be permitted to refuse to provide or participate in practices they believe to be unethical. They should be able to do so without the threat of negative repercussions. Medical schools and residency training programs should not be required to teach procedures that violate their moral code.
3. No professional organization, governing body, or governmental agency should ever mandate participation in medical practices that violate the consciences of healthcare professionals or trainees. 
4. When physicians have different interpretations of scientific studies and treatment options, well-reasoned and researched options must be respected. 

1. 42usc300a7.pdf (hhs.gov)

2. 42usc238n.pdf (hhs.gov)

3. publaw111_117_123_stat_3034.pdf (hhs.gov)

4. 42 U.S. Code § 18023 - Special rules | U.S. Code | US Law | LII / Legal Information Institute (cornell.edu)

5. Section 1553 - Refusal to provide assisted suicide services | HHS.gov

6. Stahl RY, Emanuel EJ. Physicians, Not Conscripts - Conscientious Objection in Health Care. N Engl J Med. 2017 Apr 6;376(14):1380-1385. doi: 10.1056/NEJMsb1612472.