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principle of autonomy. [ACOG Committee Opinion 63, Sterilization of Women
Who Are Mentally Handicapped. September 1988.]
Honest and ethical reproductive care should ensure (1) that patients are given full
information about any restrictions on reproductive care provided by the medical care
practitioner; (2) that medical care practitioners counsel patients about alternative care
even if they do not provide the care; (3) that medical care practitioners are not bound to
provide elective care that is abhorrent to their religious beliefs; (4) that medical care
practitioners balance the medical necessity of sexual history taking with the patient’s
concern for privacy; and (5) that medical care practitioners do not compromise a
patient’s health by refusing to provide needed care in an emergency, even if the
medical care practitioner could refuse to provide the same services on an elective basis.
1. Balancing the Health Care Practitioner’s and the Patient’s Rights
The tension between a medical care practitioner’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. Although the state has the right to specify the required training and
specific factual 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arose when the ACGME rescinded the accreditation of a residency based in a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 adequate 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. [St. Agnes Hosp. v. Riddick, 748 F. Supp. 319
(1990).]
Once they are in independent practice, medical care practitioners 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 medical care
practitioner is unwilling to provide, the patient can be directed elsewhere at once.
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