Guidelines for Resolving Conflicts of Conscience

Column: Putting President Obama’s “Conscience” Proposal in Context

Slideshow: A Timeline of Federal Refusal Rules

Video: The Role of Conscience in Health Decisions

In a perfect world, no caregiver would be compelled to perform duties they considered morally offensive, and no patient would be deprived of any legal product or service as a result of caregiver conscience alone.

Yet conflicts of conscience arise. And everyone involved in the health care system—from patients and families to doctors, nurses, pharmacists, and emergency medical technicians—needs guiding principles to help resolve issues as they occur. The Center for American Progress recommends the following:

1. Always put patient needs first in an emergency. Caregivers* should provide patients with the appropriate medical product or service in emergency situations where the patient’s life or health depends on immediate action—even if the caregiver deems it offensive.

2. Allow for refusal with conditions in nonemergencies. Caregivers may ethically opt out of their responsibilities to a patient or client in nonemergency situations if they meet the following conditions:

  • Inform the employer. The caregiver should, before being hired, inform his or her employer about any conscience-based limits to the kinds of services he or she is willing to provide.
  • Alert potential patients and clients. Any institution with such employees should give notice to all new and potential patients and clients—including those considering choosing a health insurance plan that might direct them to the institution. The institution should declare the possibility that certain identified services may not be available at all times and under all circumstances because of the conscience-based objections of some employees.
  • Establish a referral plan. Institutions should have a plan in place for referring nonemergency patients to qualified, alternative providers who are willing to provide the products or services in question. It should make the plan available to all clients and patients.
  • Make referrals convenient and affordable. The institution should satisfy an appropriate standard of fairness by making sure that identified alternative caregivers are located within a reasonable distance from the referring institution relative to the severity of the medical conditions they would treat. The institution should also ensure that the alternative caregivers are willing to perform their services on remunerative terms similar to those of the referring institution—for example, by accepting the same insurance or otherwise ensuring that the patient will not incur significantly higher out-of-pocket expenses for a legally prescribed or indicated product or procedure.

3. Never withhold information. Every caregiver has the responsibility to at least fully and fairly inform patients about all of the legal medical options that are relevant to the patients’ needs, including options the caregiver may consider personally offensive. The caregiver should refer patients or clients to providers willing to fulfill those needs if he or she is unwilling to provide them.

4. Make clear when recommendations are based on personal values. Caregivers should be explicit about the extent to which each of the recommendations they make about a patient’s treatment is based on commonly accepted best medical practice or on the individual values of the provider.

5. Enforce refusal policies. Enforcement and remedies are often key to successfully implementing policies that require a compromise between advocates with opposing views. Just as caregivers can sue institutions for employment discrimination based on the institution’s alleged failure to accommodate their refusals—so should patients be able to sue the same institutions for failing to provide legally requested services or referrals. History suggests that unless there is symmetrical legal pressure, economically powerful institutions are likely to trump individuals’ civil rights.

CAP also supports statutory efforts by states to allow medical doctors to dispense prescription medications directly to patients when the only reasonably accessible pharmacies refuse to fill those prescriptions as a matter of conscience.

*The term “caregiver” above refers to any people—licensed professional or otherwise—who play a sufficiently direct role in patient or client care such that their refusal to perform their duties would interfere with a patient’s or client’s access to legally prescribed products or indicated services.

For more information, see: