The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Tuesday, August 08, 2006

Baa-Baa Black Sheep

In my family medicine group, I always seem to have the dissenting voice. And as those of you who are loyal blog-followers know, that voice isn't a quiet one. Recently, one of my co-residents shared a story about a friend of hers in BC who was refused a prescription for the birth control pill. Apparently this physician (not her regular family doctor but a locum while her doctor was on vacation) is Catholic, and prescribing the pill went against his values. She was asking the group if we'd ever heard of this before, and if it was legal.

Well, yes. It's legal. And many of us had heard of it, but more in the case of Plan B (aka the Morning After Pill) than the birth control pill. Quite a few physicans (and pharmacists, for that matter) have been known to refuse to prescribe or dispense the morning after pill under the premise that it aborts a fetus. For those who believe that life begins the moment that sperm meets egg (like that Eliza-bitch on The View... uh, the secret is out. I read celebrity gossip magazines at the gym.) prescribing or dispensing Plan B would be like being accessory to murder. But that's not what I want to talk about.

I know of a woman who was recently faced with a horrible choice. After receiving a high risk result on her maternal serum screen, she was faced with the very real dilemma of whether or not to undergo a second-trimester termination or continue with the pregnancy, knowing that she had a very good chance of giving birth to a baby with a severe developmental delay. She opted to have an amniocentesis, in spite of the 1% risk of miscarriage, to confirm whether or not baby actually had the chromosomal abnormality. Baby was fine. But that's not what I want to talk about either.

When this woman was weighing her options, she learned that a second trimester termination, regardless of the indication for it, wasn't available in her hometown. She doesn't exactly live in a rural area-- her town has a population of over 100k people, but she would have had to travel 3 hours to another centre. The reason that this procedure isn't available is because too many nurses had opted out of it. They found it "wrong". Even in the case of a severely deformed or damaged fetus that would be unlikely to survive more than a few hours after birth, these nurses have decided that it is wrong to abort a fetus after 12 weeks gestation and have been given the option to absent themselves from this aspect of their work. Once a critical number of nurses decided not to assist in this procedure, the hospital eventually was forced to stop offering this service altogether. So now this incredibly difficult and emotionally devastating process has to be done while she stays in a hotel in a strange city, away from her support system.

No one uses second trimester abortions as birth control. They are difficult procedures, both emotionally and physically. And like any termination (in my opinion, anyway) it isn't easy to perform. I've never taken any termination I've attended lightly, even the ones done at 10 weeks where the fetus is barely distinguishable from the other products of conception. But is it really ethical to take the choice away from women simply because nurses don't want to participate?

The other family medicine residents believed that it was perfectly within any health professional's rights to refuse to participate in a treatment or procedure that they find morally objectionable. I was, once again, the outlier. I believe that if our refusal to participate in said treatment compromises a patient's access to it (such as the case of the woman in need of the termination, less so for the woman requesting the birth control pill) that it then becomes immoral to abstain from providing it.

As health care providers, sometimes we have to put our personal feelings and judgements aside for the benefit of our patients. Am I judging the 16-year-old who is pregnant with her second child? Sure I am. But I'll treat her threatened miscarriage the same as the 29-year-old married woman who had been trying to conceive for 5 years. And the alcoholic who cracked his head on the sidewalk outside of the pub? He'll get the same suture job as the child who fell off her bike. Because even if I'm secretly thinking that the person I'm treating is a waste of oxygen, no one will ever know I'm thinking it.

So to these nurses who refuse to participate in second trimester abortions? You became a nurse. You chose obsterics and gynecology. You don't get to pick and choose the parts of your job that you enjoy and refuse to do the ones you don't. If that were the case, I'd spend my time in emerg treating actual illness and not the drug-seekers, the addicts and the drunks. Sure, second trimester abortions aren't pleasent. Neither are the early abortions, for that matter. But for women to have a choice, someone has to do it. And if we as health care providers keep passing the buck on the grounds of moral objection, that freedom of choice is in real danger.

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Blogger Kungfukitten said...

I'm assuming these nurses would gladly take in these very sick special needs babies and care for them. Right? [/sarcasm] A lot of what you wrote about (but didn't want to talk about :) ) raised my hackles. (Where is the hackle located, anyway?) As you can guess I'm pretty liberal in my thinking, and get enraged when I read about people unable to get the morning after pill or an abortion when they need it. I can't imagine being already traumatized by making such a choice in the first place then having a doctor, nurse or pharmacist refusing care and forcing their ideology on me.

With that said, I think you're a good doctor by realizing that there are many people who make stupid or unpopular choices but supporting them anyway because they are your patient and need your help. (I just looked up hackles and they are the hair on the back of the neck)

1:37 AM

Blogger My Own Woman said...

My daughter,a 3rd year residenet, and I have had many discussions regarding this very point. Mostly, we have discussed the "morning after pill" when there is a rape involved. Truthfully, I wouldn't understand a woman who would want to use it as a form of birth control because of the nature of the beast since it makes you so violently ill.

Having said all of that, and having been a nurse for a quite a while, I'd have to say that there have been a few times when I have felt objectional when asked to give "questional" treatments and have agrued with physicians for withholding treatment that I felt should have been rendered.

In my humble (and sometimes not so humble) opinion, it is my obligation to do what is best for the patient, not necessarily what is best for me. If I deeply object to a specific treatment and do not wish to perform the required task (which I have not done as of yet in my nursing career), I think I would just ask one of my fellow nurses to do it; one that does not hold the same views as I do.

Trying to get a physician to do something that you think should be done is another matter. I remember vividly fighting with a physician (not an ER physician by an Ob/Gyn) to do an emergeny C-section in the ER because the 9 month pregnant woman had shot herself in the head. She was not vivable, the infant was. I begged for him to perfom the procedure. He refused because the liability was too great.

Sometimes, no matter how we feel, we just can't win.

8:41 AM

Anonymous grass said...

Actually - I think it's questionable whether that is legal or not. I'd argue it's unconstitutional, sort of like the Morgentaler case.

10:39 AM

Blogger where am i and why is my cat wearing a dress??? said...

two comments-
firstly, i do know someone who has had a 2nd trimester ta. she was 25 weeks and the ultrasound tech under dated the gestation in order for the abortion to take place. i'm not going to go into my personal beliefs on this one (because it shouldn't enter this), but she managed to get one done in washington state last month. it's amazing what 2 grand will get you.

secondly, i agree with you wholeheartedly with regards to nurses/pharmcists/doctors whose personal beliefs interfere with patients' treatment. you (collective you) don't want to give a 15 year old the bcp. you don't want to perform the abortion she's going to end up needing as a result. are you
going to take this baby in and raise it? didn't think so.

i have been a nurse long enough to have performed a few treatments for a few people. no, i don't really like having to take care of the 18 year old ivdu who has endocarditis and has had a thoracotomy, yet continues to use. but that's my job. plain and simple. and if i don't want to care for her, there's the door.
and i love the blog!

10:46 AM

Anonymous Charms said...

Well said, Couz. It really frosts my pumpkin when professionals make choices for their patients/clients. Like you, I believe that when people enter a profession they are obligated to work in the best interests of their patients/clients... even if that means providing services that they don't personally agree with.

Keep being the voice of dissention. It's people like you that help to make changes.

11:07 AM

Blogger Jenjenjigglepants said...

The scenarios presented here burn me up too. People just never seem to understand that others don't have to do what they themselves would do in the same situation. Why? Because there is no such thing as "the same situation" between people. No one has the same mix of family, experiences and sense of self that makes the choice of what to do in many medical situations cut and dried.

The reverse of your "nurses make a choice" example is equally frustrating: patient is given a treatment choice. Patient given opportunity to become "fully informed" (to the extent that's possible anyways). Patient chooses the best choice for him/herself and/or family. Choice chosen is least favoured by any/all of the health care team. Patient then has to listen to all manner of persuasion/argument in hopes they'll come around to the "right" choice.

Sorry if that's convoluded: big issues, small space...

(Second the "love the blog" motion, All in favour? Motion carried.)

4:26 PM

Anonymous Me said...

This sure is a sticky issue. I feel like health care professionals should be able to opt out of oroviding care they find morally objectionable. I feel that way because I am against circumcision of healthy children and feel that doctors shouldn't have to perform them if they find them to be wrong (I wish more docs did find them to be wrong).

It's not really a different issue, is it, b/c you're talking about a physician refusing to do what the parent (pregnant woman) tells them to do b/c they see the rights of the child (fetus/embryo) as trumping the needs/desires of the parent (pregnant person).

5:21 PM

Blogger Couz said...

Shit. You're right, me. And you've just outed me as a complete hypocrite. See my earlier post entitled 'whose penis is it anyway?'.

Apparently, I don't practice what I preach.

7:58 PM

Blogger Miette said...

Hi Couz,
Don't be hard on yourself. Abor tion and circumcision are heated topics, and it's only human to feel strongly about them one way or another, even if these views don't mesh philosophically, kwim?

Before I saw your comments, I wanted to say that I am amazed at how many people in my medical school class feel that not prescribing the birth control pill is a-ok. Amazed and saddened.

Unfortunately, it is often those who do not want to give women access to contraception who also oppose abortion. Talk about a situation where the female patient never wins.

--Miette (aka chemgirl from hitched/TB)

2:00 AM

Blogger Dr. Wannabe said...

Well it looks like on this blog I'm going to be the outlier.

I think it's pretty hypocritical to say that the physician who refuses to preform an abortion is forcing their beliefs on their patient. I would make the arguement that forcing a physician to preform an abortion is forcing someone else's beliefs on the physician. Just because someone decides to become a physician doesn't mean they are the patients servent and do whatever the patient wants. If someone goes to a plastic surgeon asking to completely redo their face, but the surgeon says he won't because he thinks the patient is mentally unstable that wouldn't be considered forcing what the physician belives on the patient. **I'm Not Saying That People Who Have Abortions Are Mentally Unstable**

And one should also look at this from the perspective of the physician. The whole reason he won't preform the procedure is because he believes the fetus is a person and could also be considered his patient as well. No one should force a physician to choose sides.

I'm sorry that these people are having a hard time getting what they want. I'm not for taking away their right to choose. (Actually, that's a completely different topic.) But I'm certainlly against making physicians go against their beliefs on THIS SPECIFIC TOPIC.

This arguement is not intended to be used for the issue of treating drunks, child molestors, overall wastes of life, etc.

Don't be mad at me. I still love the blog. I just don't agree.

2:42 AM

Blogger Couz said...

Hey, it's a free blogosphere. You're allowed to disagree... particularly when you share your viewpoint so diplomatically. That's what makes the "comments" section interesting.

And welcome, chemgirl! I recognized your avatar immediately, and was surprised to see it attached to a different name. Glad you cleared that up. ;-)

6:32 AM

Anonymous Anonymous said...

I'm an EM intern and had a case like this recently. I am also an outlier. I had a woman come in who had schizophrenia (I think, actually, it was cocaine-induced psychosis, because she had been off meds for 3 years, holding jobs without hallucinations, and seemed flat affected but otherwise normal besides intermittent crack use) and was listed as "psych eval." I went to see her, asked her what her story was, and she said that she was depressed and wanted to kill herself. I asked why, and she said she hated having to hold a job because she gets angry....and she just got raped last night.

So we went through the whole thing, called a nurse in who specializes in rape kits and such, collected the evidence, and got the patient all set. At the very end of my shift, the nurse came up and said that the pt was interested in "STD and pregnancy prophylaxis." I'd never heard it said that way. I thought about it really, really hard. I thought about how she was in no social situation to be raising a child, had some sort of mental illness that was making life hard enough for her, that if she was pregnant it wasn't because she wasn't being careful, that she was especially vulnerable right now because of all she'd been through and I needed to be sensitive to that. I tried to make myself write the order and then do some serious self-examination later when I had more time to give the issue proper consideration, but I just couldn't do it. It was the end of my shift, so I signed her out to someone who could and made her wishes known. It was weird. I am against abortion, except in the case of ectopics where the baby is never going to get to breathe air whether the mother lives or dies. I felt very strongly that it was wrong for me to give the Plan B, and I felt very strongly that regardless it was neither the time nor my place to talk to her about it, so I never said anything to her about my position. If I were the only doctor for miles, I still don't think I could do it. And I guess it comes down to rights. Plan B, really, only has a 1 in 100 chance of preventing a pregnancy, and the mechanism is actually uncertain. It probably prevents fertilization sometimes and it probably prevents implantation of a fertilized egg sometimes. So the question is which right triumphs--the patient's right to get what she wants or the physician's right to not have to do something that has a 1 in 100 chance of violating her reason for being a doctor? (Bear in mind that 100 Plan B's later, to me, I have prevented someone's existance.)

My stance on the whole morality-of-abortion-for-rape issue has been altered by a person I knew in high school. We grew up together, and just before we graduated I found out that she was adopted. Her biological mother had been raped, decided to keep the baby and give it up, and it was this brilliant, cool girl named Amy that was glad to be alive.

I think that if someone wants to have an abortion but has to drive 3 hours for it, that is morally preferrable to legally forcing a physician to either quit practicing medicine or provide a service that they feel is very wrong in order to spare the patient the time and stress of travel during a very difficult time.

And, for what it's worth on the hypocrite front, my husband and I are planning on adopting kids in addition to having biological ones. And not adopt like "wait in line for 3 years or pay 15 grand to get a healthy baby from a 20 year old female with an SAT score of 1550," but as in taking in kids stuck in the system that need families to belong to. It's something I feel very strongly about. I've got it so good, I've got to share the love and resources, you know?

8:09 PM

Blogger Sid Schwab said...

As with all issues where religious view is at the core, it's a tough one. But to me, allowing a doc, a nurse, a pharmacist to refuse care based on religious view is no different than saying a firefighter needn't rescue a gay man from a burning buliding... There are times when we're obliged by what we've chosen to do to set aside certain personal beliefs.

12:43 AM

Anonymous Alice said...

Couz - Why should a patient's "right" to do what she wants trump the physician's right not to do what they think is wrong? We're not objecting because of some vague "bad feeling" about abortion (which I think includes Plan B); we're objecting becaus we think it's morally wrong, that it's murder. There is no reason on earth why someone should be obliged to commit murder, even if the murder is only in their own minds.

Dr. Schwab - Rescuing someone from a burning building is an emergency - no time to think about it - and it's to save life. That's not at all the same situation as deliberately deciding to take away life.

2:18 PM

Anonymous Anonymous said...

As usual, Couz, I have learned something from reading your blog. It has certainly made me think, something that I don't do enough of in my profession. Thanks for the hard thoughts.


10:12 PM

Blogger Medstudentgod said...

I'm rather uncertain at this point what I believe is the best option. Either way someone is losing. I believe in abortions for rapes, incest, and severe birth defects that would almost certainly lead to a child dying before their first birthday or that threaten the life of the mother. I am also in favor of the "morning after pill" as I don't see a child at this point of gestation.

However, after the first trimester I am shaky. I was once completely anti-abortion (more based on transferece from my parent's beliefs), but the more I learn and understand the less certain I am.

Great post...I had wanted to comment for a few days, but thought what my position truly was - only to realize that I still don't have a defined one. Got more to think about.

12:04 PM

Blogger ICU 101 said...

i've said it before in the original discussion, but i think it bears repeating: after 6 years of nursing in 3 provinces and numerous hospitals, i've yet to see a hospital that allowed nurses so much authority as to completely deny a community a service...

if the hospital truly wanted to offer the service, i'm sure it could be arranged... the fact is, we don't know why the hospital doesn't offer the service... except for the hearsay info given to the woman you discussed by her doctor... which may or may not be true... i find it sad that, once again, that nurses been targeted as a scape goat...

i stand by any health professionals right to refuse to assist in a procedure they are morally opposed to... i don't believe that anyone should compromise their beliefs just because it's "their job"... as long as they do not abandon the patient...

having said that, if they don't want to participate in 2nd or 3rd trimester terminations (which i believe people should have the right to), then there are plenty of other areas of nursing they could take up in order to avoid that dilemma...

the bottom line is, as sad as the situation you described is, that our health care system has many pit falls... many communities do not have every service that we may be entitled to... that's just how it works, due to lack of MDs and support staff or proper facilities...

6:27 PM

Blogger Surgeon in my dreams said...

I have come back over and over to this particular post and wanted to comment so badly. I didn't because I knew I would be the minority, and I hate confrontation, but today I think I'll go ahead and comment since the issue doesn't want to leave my mind.

I was a surgical technologist for a short time in my younger years. I personally refused to work on abortions. I would care for the mother before or after, but I could not help during the procedure.

I don't think any health care worker should be required to give up their beliefs simply because they chose health care as their profession.

2:23 PM

Blogger Carina said...

This is a tough area, even for med spouses like me. We're the ones who deal with the doctor and nurse fallout, anyway.

There are times and cases when it's an issue of mercy. What is the merciful, the most humane thing to do in that case? That's what I ask my husband, and that's what he usually goes with.

8:20 PM

Anonymous Anonymous said...

Another way to see this from the doctor's point of view is that we are committed to fight disease. Pregnancy is not an illness, in fact oral contraception interferes with normal physiology, so I think the physician has the right to refuse to prescribe BCPs, give the morning after pill, or to perform and abortion.

8:25 PM

Anonymous Kim said...

Well, I came to terms with it a long time ago and this is what I decided:

While I could not do anything to assist in a TAB, I had an obligation to care for the patient without judgement after it was done.

So physically participating in the act itself (or the preparation for) was something I felt I could not do, I honestly did not judge the patient for the decision.

I also believe that birth control should be available, including the "morning after pill" to any woman who requests it.

My thinking on that score is that the pharmacist does not force the patient to take it, therefore they cannot judge the reason for the prescription.

What if my pharmacist believed that Ativan was a dangerous drug and no one should be treated for anxiety? Does that mean his opinion should decided whether or not I get my med?

Obviously I chose not to go into OB nursing, but I have taken care of post-op TABs when I have floated to the GYN side and I did it without prejudice or judgement.

Now, realize that I live in a large metropolitan area with many, many venues for women to get whatever care they want.

My personal decision affects no one, really. But I can't override the deep personal conviction that assisting in a TAB would not be the right thing to do for me. And yes, I think in this situation my feelings should be (and are, by the way, by law) respected.

5:50 AM

Blogger Liana said...

Lots of good comments here... I think as a doctor, you can choose not to be involved in procedures which you find morally objectionable, but at the same time, you have a responsibility to your patient to do what's in their best interest. At the very least, you need to refer your patient to another physician who will help them in a timely manner. (So where does that leave us in Nowheresville, Alberta where the doctor is against abortion/the morning after pill/whatever?)

7:44 PM

Blogger Justbeingreal said...

Not only do nurses opt out of providing abortions, but also doctors, so that we are clear. You also prsented this issue as if the only reason such professionals opt out is for thier own sake. Many medical professionals I know (including doctors) do not provide these services because they truly believe that it is NOT in the best interest of the primary patient, the mother.

2:30 PM

Blogger Alison Cummins said...

Individual doctors may believe that prevention or termination of pregnancy is not in the best interests of the patient, but they are recognised medical treatments.

Cocaine is not a recognised medical treatment; neither is amputating a healthy body part for the pleasure of a fetishist; neither are antibiotics for a cold. Doctors who refuse to prescribe cocaine or amputate the legs of fetishists or treat colds with antibiotics are refusing to provide “services” not in the best interests of the patient — and which are not recognised medical treatments, either.

But pregnancy prevention is a recognised medical treatment. It’s up to the individual to decide whether she wants to have a baby every year or not. It’s not up to the doctor. Maybe the doctor’s wife is giving birth every ten months, which I don’t happen to think is good for anybody, but the doctor has no business deciding that all women should. Really not. And if that doctor is the only one in the region and refusing to provide birth control for local women, that’s completely unacceptable.

Circumcision is the same in some ways — refusing a medically recognised service in the name of personal beliefs — but different in that the consequences are not that a big deal. Besides, the medical evidence doesn’t really add up one way or another. So it isn’t really a medical decision anyway. Not looking like your dad is not comparable to giving birth every year. (Refusing to circumcise Muslims or Jews is different again — in this case the consequences of refusal to circumcise can be quite significant.)

Abortion is a medically recognised treatment with a tremendous impact on people’s lives. And it’s up to every doctor and hospital to ensure that the women in their community have access to it.

An individual doctor might have a personal belief that being gay is a sin, that two men making love to one another is disgusting and that gay men deserve to die of AIDS. This might be a very profound, personal and religious conviction backed up by the fact that the doctor knew a gay person in grade school they disliked. But the patient is entitled to care because treatment for AIDS is medically recognised and patients are allowed to choose to be treated. The doctor doesn’t get to make these decisions. The doctor’s beliefs just don’t enter into it.

Something that doesn’t get touched on is that most people dislike performing abortions. A friend who worked in a hospital said that nurses regularly rotated out of the abortion schedule. They could do it for just so long and then they had to rotate out. It was just too difficult. I think we can recognise and sympathise. But note that the nurses were taking their turn, doing it as long as they could stand, then rotating out. Nobody was being denied a medically recognised treatment, or having major choices about their lives made for them by nurses.

Most people hate working in abattoirs too. They rotate out when they can. And people in the SPCA hate gassing the kitties. They rotate out of that when they can too. But hating doing something is not a reason not to do the right thing. And letting people make a legal and medically recognised choice about their own bodies and lives is the right thing. It’s not up to a doctor or nurse to decide that a fetus trumps the mother.

If you don’t want to treat fertile women, go into gerontology. Otherwise, suck it up.

8:27 PM

Anonymous Anonymous said...

I think just like any patient should have the final say in their care, the doctor should have the right to have the final say in what he is comfortable providing. I don't see not being comfortable with abortion, or morning after pill as terrible, even if I don't believe it myself. And though it is sad that the patient might have more emotional difficulty, that absolutely does not mean the doctor (or nurse) should compromise their values. Doctors have enough responsibility and sacrifice enough to help communities, I would never be so assuming to expect them to sacrifice their moral beliefs.

6:34 PM


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