Can she do that?

January 9, 2010 8:24 AM

A Questions about the ethics of my last Ob./Gyn/ Visit...

Here's the short of it: Last year I had an abortion and this year when I called to schedule my yearly pap I was told I was no longer a patient of Dr. X. Surprised, I asked why and the nurse said she wasn't sure why and after some hemming and hawing put the doctor on the phone. The doctor informed me she had dropped me as a patient because she didn't see women who had had abortions as it put her in a morally questionable spot. I asked how it put her in a morally questionable spot and she said she didn't have time to discuss it further and she hung up.

So here's my question: Is that right? Can a doctor drop a patient (without so much as a letter even!) for having a procedure they don't approve of? I've heard of people being fired from their doctors after failing to take medication properly etc. but never for this.

Added Bonus: It was last year right before Christmas when I went in to her office to have a second test to see if I was pregnant. My SO and I had already discussed the options and decided on a course of action the day I went in so when I got the news I asked her for a referral. She said the nurse would call me back with the necessary information. After calling the office 3+ times in a week to get said information. I gave up and called Planned Parenthood myself.

[This question isn't about whether or not you think my abortion was morally right. The choice to have or not have a child is a personal one that I don't think is best debated in internet forums. This is about whether my doctor can drop me as a patient just because I've had an abortion. Thanks metafilter!]

posted by julie_of_the_jungle to health & fitness (27 answers total)

IANAD, nurse, or medical ethicist. But from what I know, dropping you as her patient was ethical, though she should have provided you with a letter -- doctors can and do drop patients all the time, for any reason. However, once she said she would give you a referral, she was NOT ethical in simply refusing to do so. She should have either refused up front, verbally, or given you the referral information promptly. That one probably deserves a letter.
posted by KathrynT at 8:30 AM on January 9, 2010

Wow. I would contact your state's licensing board, and if your doctor is affiliated with an HMO, I would contact them too. I know there are many doctors out there who may believe different things than their patients, but you had no way of knowing the doctor's beliefs beforehand, so she put you in a very difficult position during an already-difficult time. To simply avoid the situation and not provide a referral for further service seems completely uncalled for. Your doctor is there to serve you and provide what you need.

I've heard of pharmacists putting people in this situation, but this seems less common -- and more troubling.
posted by Madamina at 8:33 AM on January 9, 2010 [2 favorites]

With the benefit of hindsight, you can now see the probable motive for your physician to fail to provide the promised care (in this case a referral, last year) that you were relying on, which endangered your health by needlessly delaying your abortion.

Your physician's actions last year are far more egregious than dropping you as a patient now, but the current actions allow you to fully explain what happened before. Send a complaint to your state board of medical examiners, and concentrate on that aspect as dropping you is more of a red herring.
posted by grouse at 8:36 AM on January 9, 2010 [13 favorites]

I can't tell if you're asking whether it's ethical or legal. Can you clarify that? You say something about ethics at the beginning, but twice you say the real question is about whether the doctor can drop you for [reason she thinks is sufficient but you don't]. Is that your real question though?

She did put you in a tough spot and she could have done it with more class and/or professionalism (a letter, maybe a referral to a new doctor). But do you want her as your doctor anyway? It's for the best if she can drop you for this reason. If she thinks you endanger her somehow now that you are [whatever], you cannot trust her to act in a way that's best for you as a patient. It is for the best. You can find a different doctor now, and maybe you've dodged a bullet too.
posted by fritley at 8:46 AM on January 9, 2010 [1 favorite]

IANAD, but yes, it's definitely legal. Unless it's an emergent situation, doctors have the right to choose their own patients.
posted by roomthreeseventeen at 8:56 AM on January 9, 2010 [1 favorite]

I believe it is legal for any doctor to drop a patient from care with 30 days notice and, in most cases, are required to successfully transfer care to another physician. But they do need to provide a letter. There are federal and state laws and guidelines regarding being dropped from care, so I would definitely google around and call the appropriate department within your state to ask (department of health or the medical commissioner's office perhaps).

That you didn't receive a letter regarding the doctor dropping you from practice is concerning, though the action in of itself of dropping you likely fell within guidelines. But you should have received notice through a letter.
posted by zizzle at 9:04 AM on January 9, 2010

If an OB/Gyn prefers not to treat patients who have had abortions, and/or refuses to provide referrals, that office should advertise that fact. I would not choose to have that doctor, and I find this behavior questionable, and yes, complain to the medical board in your state. You'll find them through the state attorney general's office, which almost certainly has a web page.
posted by theora55 at 9:05 AM on January 9, 2010

So here's my question: Is that right? Can a doctor drop a patient (without so much as a letter even!) for having a procedure they don't approve of? I've heard of people being fired from their doctors after failing to take medication properly etc. but never for this.

Physicians have an ethical obligation to provide treatment to patients when it is medically necessary. If for some reason (including their own "conscientious objections" to providing care they think is morally unacceptable) they can not or will not perform medically necessary care, they must refer the patient to someone who can provide them with that care. For example, if a doctor considered a life-saving therapy derived from stem cells to be morally objectionable, she is not obliged to use the therapy herself, but she is under some obligation to ensure that her patient can be referred to someone who can provide it.

The case of abortion is difficult, particularly in the U.S., because whether or not it is considered "medically necessary" depends a lot on the particular patient's situation. In addition, anti-abortion activists have introduced legislation in several states that includes "conscience clauses," which allow health care professionals to abstain from "participating" in procedures that they find to be morally objectionable - including counseling or referring patients for those procedures. So there is some precedent, and in some cases some legal backup, allowing physicians to refuse to even give you a referral.

That said, almost all ethicists and physicians agree that a doctor's personal judgments about a person's moral character should play no role whatsoever in their treatment decisions. Emergency room doctors are obliged to treat both the shooter and the victim in an assault; pulmonologists are obliged to treat lifelong smokers; OB/GYNs are obliged to treat patients who repeatedly become infected with STDs without taking precautions; and so forth. Its widely accepted that doctors have a duty to act as healers, not judges.

So I would say that, from an ethical point of view, no, it is not right for your OB/GYN to refuse to treat you because you have had an abortion in the past. This crosses the line between refusing to provide a specific treatment that a physician finds morally objectionable, and refusing to treat an individual that a physician finds morally objectionable. However, as others have indicated, in practice physicians exercise broad discretion to determine who they can treat, and who they can drop from their practice. It's not right, but it is technically legal.

References, if you are interested: 1, 2.
posted by googly at 9:27 AM on January 9, 2010 [3 favorites]

Although the physician could have done a better job communicating with you, they have the right to not take you as a patient.

I am a R.N. working in surgery. I have the right to decline taking care of (circulating the case) someone that is scheduled for an abortion IF it is against my beliefs. I could also refuse to "circulate" a case if it is for a tubal ligation, IF this procedure is against my beliefs. (There are laws that are in place for these situations) When I've been in charge, sometimes I would have to find different nurses to work the "case" and sometimes a different anesthesiologist, (they can also decline to "do the case". Keep in mind, this is for a therapeutic abortion, aka TAB. If it were a case of life or death, different story, (like a tubal pregnancy).

Pharmacists can choose to not fill the morning after pill if it is against their beliefs. I am old enough to remember people having difficulty getting their birth control filled if it was against the pharmacist's beliefs. My sister, as a teenager, had severe menstrual cramps. It took a long time (think a year or two) before the doctor would prescribe BCP for her, because it was against the doctor's beliefs.

On preview, what googly said.
posted by 6:1 at 9:50 AM on January 9, 2010 [1 favorite]

While the issue of providing the abortion itself, conscience clauses and the like are a thorny issue, one issue that is not the least bit unclear to me as a practicing physician is that your doctor picks and chooses which patients she provides routine care for based on some moral judgment she has made of them. That to me is highly unethical, and I suspect that reflects the general consensus on this.

With respect to the time of the abortion itself, the American College of Obstetrics and Gynecology (ACOG) would find her failure to provide prior notice to you regarding her policy, and her failure to refer you to another provider in a timely manner both to be ethically unacceptable.

Quoting from their latest statement on "The Limits of Conscientious Refusal in Reproductive Medicine" [pdf]:

"Where conscience implores physicians to deviate from standard practices, including abortion, sterili- zation, and provision of contraceptives, they must provide potential patients with accurate and prior notice of their personal moral commitments."

"Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that their patients request."
posted by drpynchon at 10:27 AM on January 9, 2010 [3 favorites]

I had an OB/Gyn that refused to prescribe birth control because she was a Catholic and it violated her morals. I found a new doctor when it came time to get the pill.

It's the doctor's right to do what she did. Ethically, I don't know. I DO know she should have informed you of her beliefs IMMEDIATELY so you had time to find a new doctor.

I would definitely register a complaint against her, simply for her failure to make you aware of her beliefs and decision to drop you as a patient.
posted by elsietheeel at 11:15 AM on January 9, 2010

I understand how upsetting it may be to be told that the doctor will not treat people who have chosen to have an abortion (which admittedly seems absurd for a doctor to do), but many commenters' desire to see Julie punish the doctor (by notifying the medical board) for acting on her moral commitments, when she has not harmed Julie in any way, seems rather small-minded. Surely Julie doesn't want to continue going to a doctor who does not want to treat her?
posted by jayder at 11:20 AM on January 9, 2010 [1 favorite]

jayder: What moral commitments preclude providing routine care for a woman who had an abortion last year? Are they similar to the ones that would preclude taking care of someone who smokes or is obese? What about the ones that might preclude taking care of blacks or jews? Maybe they are the ones that might preclude taking care of prison inmates or ex-cons.

Again, refusing to perform abortions is one thing, but the issue is bigger than this. Refusing to provide any care for someone because they had an abortion previously is entirely another. To me that's totally beyond the bounds of any reasonable "conscientious refusal," and I think physicians need to be held to a higher professional ethical standard than what you describe, lack of any physical harm to Julie not withstanding. I might not report it, but I wouldn't hold it against anyone if they did.
posted by drpynchon at 11:49 AM on January 9, 2010 [16 favorites]

While fucked up, I think it's very ethical for her to drop a patient when she has moral qualms about the relationship.

What was wrong was not notifying you.
posted by cmoj at 12:00 PM on January 9, 2010

I understand how upsetting it may be to be told that the doctor will not treat people who have chosen to have an abortion (which admittedly seems absurd for a doctor to do), but many commenters' desire to see Julie punish the doctor (by notifying the medical board) for acting on her moral commitments, when she has not harmed Julie in any way, seems rather small-minded.

While fucked up, I think it's very ethical for her to drop a patient when she has moral qualms about the relationship.

To repeat what I said above, and echo drpynchon: there is a difference between a physician refusing to perform a particular procedure that they judge immoral, and refusing to see a person whom they judge to be immoral. You as an individual may have no problem with the latter, and you are of course entitled to your judgment. But it is widely accepted that physicians should not use moral evaluation of a patient as a basis for their decision to provide routine care. Here is a relevant section from the American Medical Association's Code of Ethics:

Opinion 10.05 - Potential Patients

(1) Physicians must keep their professional obligations to provide care to patients in accord with their prerogative to choose whether to enter into a patient-physician relationship.
(2) The following instances identify the limits on physicians’ prerogative:
(a) Physicians should respond to the best of their ability in cases of medical emergency (Opinion 8.11, "Neglect of Patient").
(b) Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination (Opinion 9.12, "Patient-Physician Relationship: Respect for Law and Human Rights"), nor can they discriminate against patients with infectious diseases (Opinion 2.23, "HIV Testing").
(c) Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat (Opinion 10.015, "The Patient-Physician Relationship").

Exceptions to this requirement may exist when patient care is ultimately compromised by the contractual arrangement.
(3) In situations not covered above, it may be ethically permissible for physicians to decline a potential patient when:
(a) The treatment request is beyond the physician’s current competence.
(b) The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, "Invalid Medical Treatment").
(c) A specific treatment sought by an individual is incompatible with the physician’s personal, religious, or moral beliefs.

posted by googly at 12:31 PM on January 9, 2010 [1 favorite]

It's a good thing she doesn't practice some weird creed that talks about forgiveness of sinners, or she might be in an ethical quandry.

Full disclosure of her biases via a sign in the waiting room would be the ethical thing to do, but that might violate the relationship between her wallet and her morality by driving away patients.
posted by benzenedream at 12:51 PM on January 9, 2010 [3 favorites]

Certainly the doctor can treat whoever they want to. But...

That the doctor dropped the ball on follow through is what's most disturbing to me about this. It's one thing for her to have her moral objections, but as was referenced by someone else, it's completely different for her to say she would help in providing information on an abortion provider and then not. (a la Crisis Pregnancy Centers)

If this was an individual doctor, I'd just tell all your friends (if you're comfortable talking about the abortion) and spread the word of mouth to stay away from the doctor. If she's part of a larger medical group, I'd contact their ombudsman/medical director and relay your experience, particularly focusing on the delay in care.
posted by herrtodd at 1:36 PM on January 9, 2010

jayder: What moral commitments preclude providing routine care for a woman who had an abortion last year? Are they similar to the ones that would preclude taking care of someone who smokes or is obese? What about the ones that might preclude taking care of blacks or jews? Maybe they are the ones that might preclude taking care of prison inmates or ex-cons.

Apart from the reference to the AMA Code of Ethics googly provided above, here is another perspective on this question: the moral commitment to provide the best care possible to your patients, and by extension the commitment to refer those patients to whom you believe you cannot provide such care to other physicians.

When a doctor is sufficiently self-aware of his or her own inability to treat a patient on an impartial, professional basis because the doctor is aware that the patient has had a certain procedure (e.g. an abortion) it may be appropriate for the doctor to refuse to take on (or retain) that person as a patient. That is, if the doctor's feelings about abortion are so strong as to colour the doctor-patient relationship in a way that would affect patient care, not only would it be ethically permissible to terminate the doctor-patient relationship, it could in fact be unethical not to do so if the care the doctor provides might be compromised as a result.

Arguably the same logic might be extended to prison inmates or ex-cons. If you were an ex-con and this were known to your doctor, would you want to be treated on an ongoing basis by a physician who harbours a secret burning hatred for convicts due to some incident in his or her past? Would you want to be an unknowing participant in that doctor's personal struggle (noble though he or she might conceive it to be) to overcome his prejudices every time you sought medical care, or would you prefer to recieve that care from a physician who could interact with you freely and clearly from the get-go?

Again, arguably this logic could be further extended to racial or other prejudices. Ideally no one who harbours such prejudice would be admitted to or remain in medical practice, but isofar as most if not all people harbour some prejudice it is important that frameworks for ethical practice incorporate mechanisms for practitioners to recognize the ways in which those prejudices may affect their ability to perform their jobs properly as well as to act on that knowledge so as to prevent prejudice from negatively impacting patient care.

None of considerations above would apply in an emergency situation, though, as others have noted. Also, IANAD, nor a bioethicist or anything like that. Just someone who took a bunch of ethics seminars and thinks a lot about these issues.
posted by onshi at 2:03 PM on January 9, 2010

I just want to say that I wish I could favorite drpynchon's comment a thousand times. My understanding is that "conscientious objection" is limited to refusing to perform a specific treatment for a patient that one finds distasteful, and does not include refusing any and all future treatment for a patient because they had a certain procedure done in the past.
posted by Lobster Garden at 2:24 PM on January 9, 2010 [1 favorite]

It was a cowardly way to care for a patient.

She could have said, "No, I do not do referrals for that procedure." It would have been uncomfortable, but it would have been honest interaction with her patient. Also, she could have informed you that she would not longer treat you either during your visit or by letter. If she was really professional, she might have told you how to gain access to your records for your next doctor. Again it would be uncomfortable, but in your best interest to allow you to be an informed patient.

She's welcome to her opinions of your reproductive choices, but that doesn't justify a sloppy, cowardly method of dropping a patient.
posted by 26.2 at 3:47 PM on January 9, 2010 [2 favorites]

She should have notified you - knowing how long it can take to be seen by a new doctor, making you find out yourself could have delayed your exam, a particularly important one after having a procedure done.

On the plus side, would you want to continue seeing a doctor who disapproves of you? Myself, I'd give a shudder and a silent thank you for finding out and being able to move to a doctor with whom I could have a more trusting relationship.
posted by Billegible at 4:03 PM on January 9, 2010

Whether or not the doctor's actions were legal, they were still unprofessional and rude. You should make a complaint in writing to your state's medical practitioner's board (or equivalent) and specify each breach (legal, ethical or in manners).
posted by kid A at 4:47 PM on January 9, 2010

This kind of thing enrages me because, whether someone agrees with the decision or not, it is legal to have an abortion in the United States. I know things get tricky with conscientious objections and states rights, and I am neither a lawyer or a doctor, so I am not sure what she did is legal or not. Still, in my mind, a medical procedure should be treated as such, and if for whatever reason a medical professional feels they cannot perform that procedure for you, as long as its not an illegal course of treatment, they are legally obligated to refer you to someone who can.

As for what's ethical, in my opinion, she can refuse to do the procedure and she can discontinue the relationship, but she has an obligation to inform you of her decision and to provide you with a list of referrals and/or instructions on how to find a new doctor. I would file a complaint with your state's medical board with an emphasis not on her refusal to provide care but with your physician's failure to notify or refer you to another provider. Depending on her insurance and hospital affiliations, you may want to file a complaint with those organizations as well.
posted by katemcd at 6:19 PM on January 9, 2010

Again, arguably this logic could be further extended to racial or other prejudices. Ideally no one who harbours such prejudice would be admitted to or remain in medical practice, but isofar as most if not all people harbour some prejudice it is important that frameworks for ethical practice incorporate mechanisms for practitioners to recognize the ways in which those prejudices may affect their ability to perform their jobs properly as well as to act on that knowledge so as to prevent prejudice from negatively impacting patient care.

The road to hell is paved with good intentions? To me what you're describing is exactly the reductio ad absurdum that leads to the only ethically appropriate stance on this: if discrimination clouds your ability to provide medical care, the answer is to find another fucking job and not waste a highly competitive spot in medical training.
posted by drpynchon at 6:57 PM on January 9, 2010 [4 favorites]

It appears that the doctor may have been passively trying to interfere with your chosen course of action by promising a referral and then not delivering. It's not small-minded at all to report a doctor who would try to impede a patient's ability to access medical care. Even the failure to notify you that she was discharging you was medically irresponsible--she deprived you of the opportunity to seek out a new doctor before you were in imminent need of care. I hope you file complaints.
posted by Mavri at 7:44 PM on January 9, 2010 [2 favorites]

drpynchon said: ...if discrimination clouds your ability to provide medical care, the answer is to find another fucking job and not waste a highly competitive spot in medical training.

I agree with you. I was all "arguably" because I don't personally hold the view that I was advancing; however, someone who does might suggest that a highly competitive spot in medical training would only be entirely "wasted" if someone, having obtained that training, used it on no one at all rather than on the patients they be reasonably sure they were treating appropriately given the prejudices they acknowledge holding and are at least making a good faith effort to avoid allowing have a negative impact on care. Not all doctors will provide care to all persons in any event, and the subtle difference between excluding a person from your pool of patients because you dislike a group x and don't want to treat them, as opposed to avoiding group x patients because you are genuinely concerned that your bias against them will affect the care you provide is ethically significant one. The key is taking an active role in ensuring that care is provided to the patient by another practitioner.

I think the general principle is that if a doctor finds him or herself unable to provide proper care to any particular patient for any reason they should take appropriate steps to direct that patient to another provider. Bringing this back to the OP's case I think there is consensus among respondents here that there was a serious failure to communicate in a clear and timely way. I think the OP deserved timely and forthright notification.
posted by onshi at 9:41 PM on January 9, 2010

There are lots of nutty doctors out there. Just accept you were seeing a nut, be glad the nut fired you as a patient, and find a new doctor who is not a nut. It's not any more complicated than that.
posted by jayder at 1:16 AM on January 10, 2010