Transcript Conscientious Objection in Residency Training

Conscientious
Refusal in
Residency Training
Jennifer Frank, MD, FAAFP
Fox Valley FMR Program
November 12, 2009
Introduction
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What is known:
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Conscientious refusal (objection) is known to
exist
Prevalence (limited data)
What is not known
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Behaviors surrounding conscientious refusal
Appropriate professional, legal, and ethical
standards
Examples of current legal and ethical
issues in conscientious refusal include
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Pharmacy dispensing of emergency
contraception
Assisted reproductive technology in an
unmarried/lesbian woman
A Survey of Conscientious Objection
in US Physicians (Curlin et al, 2007)
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Focus on prevalence and characteristics of
conscientious objectors
C.O. to legal medical practices
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17% object to terminal sedation
52% object to abortion for failed contraception
42% object to prescription of birth control to
adolescents without parental consent
1. What is the prevalence of CO in
family medicine residency programs?
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Do family medicine residents and faculty
identify a personal moral opposition to any
common, legal medical practices?
2. For those that identify a
“conscientious objection” have they?
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Identified a way to care for patients
requesting or requiring the procedure or
prescription?
Disclosed their objection(s) to their
colleagues/supervisor?
Disclosed their objection(s) to their
patients?
Methods
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An 8 item web-based survey of residents
and faculty in the UW Department of Family
Medicine
Participation was voluntary and anonymous
45% response rate (154 respondents)
IRB exempt status
Results
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Questioned on 14 practices with a range of 4122 respondents with a reported objection
The majority of respondents (87%) with an
objection to a practice had not notified their
medical director or program director of the
objection.
The majority of respondents (60%) had
developed a plan to “inform, educate, and refer”
patients who requested the procedure.
Moral Objection, self-report
100
90
80
70
60
50
40
30
20
10
0
Objection
No Objection
Perform AB for failed
contraception
Refer AB for failed
contraception
Moral objection to
performing/referring for an abortion
80
70
60
50
Objection
No Objection
40
30
20
10
0
Trisomy 21
Gender Selection
Other Moral Objections
100
90
80
70
60
50
40
30
20
10
0
Objection
No Objection
Residents may refuse
Circ
BC teens
art h/n
perm ster
Have you ever participated in medical care
that you considered morally objectionable
on the basis that the care was futile?
Yes
No
No experience
Have you ever refused to participate in medical
care that you considered morally objectionable
on the basis that the care was futile?
Yes
No
No experience
Respondent beliefs
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Physicians have an obligation to present all
information to a patient (fully disclose) about a
procedure (95%)
Physicians have an obligation to refer (90%)
It is acceptable for a physician to describe his or
her objection (70%)
A physician with a moral objection should disclose
that objection to his or her practice partners (87%)
Conclusions
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Personal moral objections to legal medical
procedures are common.
While disclosure is viewed as an obligation,
it is not necessarily practiced.
While the majority of physicians with moral
objections have a plan in place to care for
patients, a significant minority have no plan
developed.
Conclusions continued
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Physician beliefs around conscientious
refusal indicate:
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Obligation to provide information
Obligation to refer
Acceptance of disclosure of reason why to
patient
Residents enjoy the same right to refuse as
attending physicians
Implications and Future Directions
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Communication around moral objections
Exclusion of physicians with moral
objections?
Ethics education and development
Ethics education
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Ethics instruction for medical students and
residents should include:
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Discussion of the role of conscientious refusal
Assistance with communicating moral objections
to supervisors, colleagues, and patients
Discussion of legal and ethical plans of care
Discussion of moral objection around futile care
Questions?