A 28-year-old woman comes to the gynecologist, who has provided routine care for the patient over the past 10 years. The patient has not menstruated for over 2 months and had a positive home pregnancy test last week. Although she hopes to have children in the future, she has been under a lot of stress lately and says that caring for a child is the last thing she needs right now. A pelvic ultrasound confirms an intrauterine pregnancy at 7 weeks gestation, and the patient requests that the gynecologist terminate the pregnancy as soon as possible. The gynecologist does not perform abortions on moral grounds but does have training in the procedure. Which of the following is the most appropriate course of action?
Conscientious refusal occurs when a provider refuses to provide care because doing so would conflict with the provider's beliefs. Although following one's conscience—the part of the self that judges actions as right or wrong—can lead to ethical and appropriate care, it also can conflict with professional obligations. Provider conscience does not take precedence over other ethical principles (eg, autonomy, justice, beneficence, nonmaleficence).
As with any procedure or treatment, the physician should have a neutral discussion regarding the procedure and alternatives. The physician should be nonjudgmental, refrain from imposing moral values, and convey respect for the patient's autonomy. If the patient decides to undergo the procedure after neutral education, she should be provided with resources that will assist in obtaining the desired service. Providers who are unable to provide care in good conscience are professionally and ethically obligated to refer patients in a timely fashion to other providers who can provide care.
(Choices A and D) The physician is not required to perform the procedure but is obligated to provide resources to help the patient find another provider who will perform it in a timely manner to respect the patient's autonomy.
(Choice B) Encouraging the patient to reconsider her decision is inappropriate because it imposes the physician's own judgment and values. Discussing age-related infertility risks in this situation can inadvertently place guilt or shame on the patient and should be avoided.
(Choice C) Encouraging the patient to take additional time to make a decision is not advisable because this could place her past the first trimester and increase complexity/risk to the procedure.
Educational objective:
Conscientious refusal of treatment occurs when a provider refuses to provide care due to moral conflict. Providers who cannot, in good conscience, provide treatment that a patient requests, are obligated to refer the patient in a timely fashion to another provider who can. This respects the patient's autonomy.