1. Conscientious Refusal in Residency Training Jennifer Frank, MD, FAAFP Fox Valley FMR Program November 12, 2009

2. Introduction What is known: Conscientious refusal (objection) is known to exist Prevalence (limited data) What is not known Behaviors surrounding conscientious refusal Appropriate professional, legal, and ethical standards

3. Examples of current legal and ethical issues in conscientious refusal include Pharmacy dispensing of emergency contraception Assisted reproductive technology in an unmarried/lesbian woman

4. A Survey of Conscientious Objection in US Physicians (Curlin et al, 2007) Focus on prevalence and characteristics of conscientious objectors C.O. to legal medical practices 17% object to terminal sedation 52% object to abortion for failed contraception 42% object to prescription of birth control to adolescents without parental consent

5. 1. What is the prevalence of CO in family medicine residency programs? Do family medicine residents and faculty identify a personal moral opposition to any common, legal medical practices?

6. 2. For those that identify a “conscientious objection” have they? Identified a way to care for patients requesting or requiring the procedure or prescription? Disclosed their objection(s) to their colleagues/supervisor? Disclosed their objection(s) to their patients?

7. Methods An 8 item web-based survey of residents and faculty in the UW Department of Family Medicine Participation was voluntary and anonymous 45% response rate (154 respondents) IRB exempt status

8. Results Questioned on 14 practices with a range of 4- 122 respondents with a reported objection The majority of respondents (87%) with an objection to a practice had not notified their medical director or program director of the objection. The majority of respondents (60%) had developed a plan to “inform, educate, and refer” patients who requested the procedure.

9. Moral Objection, self-report

10. Moral objection to performing/referring for an abortion

11. Other Moral Objections

12. Have you ever participated in medical care that you considered morally objectionable on the basis that the care was futile?

13. Have you ever refused to participate in medical care that you considered morally objectionable on the basis that the care was futile?

14. Respondent beliefs Physicians have an obligation to present all information to a patient (fully disclose) about a procedure (95%) Physicians have an obligation to refer (90%) It is acceptable for a physician to describe his or her objection (70%) A physician with a moral objection should disclose that objection to his or her practice partners (87%)

15. Conclusions Personal moral objections to legal medical procedures are common. While disclosure is viewed as an obligation, it is not necessarily practiced. While the majority of physicians with moral objections have a plan in place to care for patients, a significant minority have no plan developed.

16. Conclusions continued Physician beliefs around conscientious refusal indicate: Obligation to provide information Obligation to refer Acceptance of disclosure of reason why to patient Residents enjoy the same right to refuse as attending physicians

17. Implications and Future Directions Communication around moral objections Exclusion of physicians with moral objections? Ethics education and development

18. Ethics education Ethics instruction for medical students and residents should include: Discussion of the role of conscientious refusal Assistance with communicating moral objections to supervisors, colleagues, and patients Discussion of legal and ethical plans of care Discussion of moral objection around futile care

19. Questions?