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Balancing the Physician's and the Patient's Rights

The tension between a physician's right to refuse to participate in certain types of medical care and a patient's right to receive care begins in medical school and residency training. The constitutional right to exercise one's religion freely has always been limited by the state's right to pass laws that apply equally to all citizens. (This was most recently reaffirmed in the decision by the U.S. Supreme Court that a state could prohibit members of the Native American church from using peyote.) While the state has the right to specify the required training and knowledge of persons it licenses to practice medicine, this is usually left to the discretion of accreditation agencies for medical training programs. These agencies determine the extent to which a medical student or resident may avoid certain procedures and still be allowed to be certified.

Medical training programs must meet the requirements of their accrediting organizations if their students and residents are to be eligible for licensing or

advanced certification after completing their training. The federal courts have recently upheld the right of the Accreditation Council for Graduate Medical Education (ACGME) to require residents in an ACGME-accredited program to receive training in abortion, sterilization, and contraception. The case in question arose when the ACGME rescinded the accreditation of a residency based in a Catholic hospital. Many Catholic hospitals prohibit residents from performing these procedures in the hospital itself. This program was unusual in forbidding the residents to perform the procedures in other hospitals, thus ensuring that the residents did not learn techniques for abortion and sterilization or have training to provide information on contraception. The court found that the training requirement was not religiously motivated. Since the requirement did not advocate a religious doctrine and was nondiscrimatorily applied, it did not violate the First Amendment protections on free exercise of religion.[164]

Once they are in independent practice, physicians must make any self-imposed limitations on the care they offer clear to their patients as early in the encounter as feasible. Ideally, patients will be asked what care they are seeking when making their initial appointment. If the patient is seeking care that the physician is unwilling to provide, the patient can be directed elsewhere at once. Under no circumstances should physicians withhold their beliefs in an attempt to persuade the patient to change her mind. Implicitly or explicitly holding out the availability of services that are not in fact available is deception.

Putting the patient on notice of the physician's refusal to provide certain types of care does not obviate the physician's duty to inform the patient when this care is appropriate. For example, if the physician discovers that the patient has a medical condition that would make pregnancy difficult, the physician must counsel the patient on the availability of contraception and sterilization. The requirement that a physician refer a patient to an alternative source of care is the same whether the physician is unable to provide the care or the physician has personal objections to the care. A physician may not abandon a patient on religious grounds. The physician-patient relationship carries with it a duty to continue care until an alternative is provided.

[164]St. Agnes Hospital v. Riddick. 748 F. Supp. 319 (1990).

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