How should a clinician act on personal values when those values clash with their employers? This is the ethical question posed in a recent case study published in the AMA Journal of Ethics.

The case study involves a physician who works for a Catholic healthcare organization that prohibits employees from prescribing contraceptives. What should a physician do if 1 of her patients comes in for a check-up and asks for birth control?

How should a physician face this kind of dilemma? According to Jane Morris, MD, and Kavita Shah Arora, MD, MBE, from the Case MetroHealth Medical Center in Cleveland, Ohio, there are a few possibilities on the table:

  • Tell the patient that per office rules, the physician cannot prescribe birth control.
  • Refer the patient to a clinician outside the Catholic health system.
  • Prescribe the medication but say that it is for a purpose other than birth control, such as acne.
  • Prescribe the birth control and risk termination.

If the physician chose the last option — to prescribe birth control despite rules in place at the organization — she would likely lose her job. Catholic healthcare organizations have terminated employees for similar actions in the past.

If the physician chose to refer the patient to another clinician, that would still go against institutional rules, as “the clinician would be complicit in the eventual provision of contraception.” In addition, referrals can hurt patients who might not have many healthcare options nearby, or who have a limited number of physicians who are in network with their insurance.

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If the physician chose to provide the patient with the prescription under a false diagnosis, such as acne, she could face legal trouble, as such healthcare fraud is a federal criminal offense. According to Drs Morris and Arora, “the US Code defines health care fraud as ‘knowingly and willfully execut[ing]…a scheme or artifice — (1) to defraud any health care benefit program…in connection with the delivery of or payment for health care benefits, items, or services.” However, the Catholic Church might allow use of birth control if the prescription is for something other than preventing pregnancy, as long as it follows the “double effect,” meaning the “good” action would outweigh the “bad.”

Dr Morris and Dr Arora recommend that physicians take the following steps when faced with this issue: first, search the patient’s medical history for an alternative diagnosis in which birth control would be an effective option and will satisfy the “double effect.” If the physician cannot find anything to fit that description, the authors suggest that the physician has a responsibility to tell the patient that the office cannot prescribe the birth control, and then refer that patient to a different physician.

The authors also recommend that physician in this position make changes to the office. For example, the physicians and staff can make sure that patients know that the office does not prescribe birth control before scheduling an appointment.

Reference

Morris J, Arora KS. Should clinicians challenge faith-based institutional values conflicting with their own? AMA J Ethics. 2018;20(7):E630-E636