July
Responses to "Abortion: Ensuring Access"
Canadian Medical Association Journal
July, 2006
Introduction
In July, 2006, the Canadian Medical Association Journal published a guest editorial by Sanda Rodgers of the Faculty of Law, University of Ottawa, and Jocelyn Downie, of the Health Law Institute, Dalhousie University, Halifax, Nova Scotia. The editorial appears to have been an attempt to bully objecting physicians who refuse to refer patients for abortion by menacing assertions about legal and ethical obligations. The CMAJ is a publication of the Canadian Medical Association, which, however, asserts that its contents do not necessarily represent the views of the Association. The CMAJ did not publish the Project's response to the guest editorial, but did publish several others critical of the position taken by Rodgers and Downie. Those below are reproduced with the permission of the authors and the CMAJ. Another, by by Dr. Daniel Holmes (University of British Columbia, Department of Pathology and Laboratory Medicine St. Paul’s Hospital Vancouver, BC) is available on the CMAJ website, as are some letters supportive of the editorial.
Moral Desensitization
Renata Leong, MDcM, CCFP, MHSc
DFCM, St. Michael's Hospital; Assistant Professor, DFCM, University
of Toronto (26 July, 2006)
. . . A call for the silencing of one’s inner voice of conscience is not without cost. Research on medical education has documented moral distress and moral desensitization when trainees witness or participate in what they perceive as unethical acts, such as making derogatory comments about patients1,2. One can only imagine the hundredfold impact of this phenomenon when a healthcare provider is faced with a perceived demand to promote or participate in the taking of another’s life. . . [Link to Letter]
Physician Autonomy and the Ethics of Intolerance
Stephen J. Genuis, MD FRCSC DABOG,
Associate Clinical Professor, University of Alberta (19 July,
2006)
. . . it may be preferable to have credible physicians debating conflict-ridden medical issues rather than sanctioning special interests outside the profession to expound unilaterally in scientific journals. . . The policy of coercing ethical doctors to do what they feel is unethical – whether it is by threat of lawsuits or disciplinary action – displays intolerance of diverse views and choice; it goes against the CMA code of ethics . . . [Link to letter]
“Physician Autonomy and the Ethics of Intolerance” — eCMAJ 19-Jul-06 —In response to the original article from, CMAJ 04-Jul-06; 175(1), Page(s) 9 “Abortion ensuring access” by permission of the publisher. © 2006 Canadian Medical Association
Balanced Journalism Needed
Rene Leiva
SCO Health Centre Ottawa (13 July, 2006)
To the editor:
I found the Guest Editorial in this week’s issue of CMAJ to be partial and misleading. (Abortion: ensuring access, CMAJ 175(1): July 4, 2006). One of the main issues is the false statement by the guest editors that physicians should refer to abortion even against their conscience: . . . [Link to letter]
“Balanced journalism needed” — eCMAJ 13-Jul-06 — In response to original article from, CMAJ 04-Jul-06; 175(1), Page(s) 9 “Abortion ensuring access” by permission of the publisher. © 2006 Canadian Medical Association
Re: "Abortion: ensuring access"
Dr. Philip Ney (13 July 2006)
Before definitively forming an opinion on the editorial “Abortion: ensuring access” by Rodgers and Downie, I would like to ask them a few questions; . . . 2) What is the scientific evidence that abortion is good and/or essential for women? 3) How can abortion be a “constitutionally protected right” for women, and at the same time, the practice of abortion be “regulated like any other medical procedure”? . . . 7) I note that Rogers and Downie think the physicians “must” or “should do” on 9 occasions. How would members of the legal profession feel about physicians telling the legal profession how to conduct their affairs? . . .
"Abortion: ensuring access"” — eCMAJ 13-Jul-06 — In
response to original article from, CMAJ 04-Jul-06; 175(1), Page(s) 9
“Abortion ensuring access” by permission of the publisher. © 2006
Canadian Medical Association
Abortion Access Editorial Worrisome
Williard P Johnston, MD
President, Canadian Physicians for Life (11 July, 2006)
It is disturbing that Rodgers and Downie have teaching contact with medical students on the topic of access to abortion. It seems clear to me that two of their central points are plainly false. . . the CMA policy on referral for abortion is unequivocal: a physician must make his or her position, and the right to consult another physician, clear to the patient but is in no way obliged to provide a referral for any procedure. . . [Link to letter]
“Abortion access editorial worrisome” — eCMAJ 11-Jul-06 — In response to original article from, CMAJ 04-Jul-06; 175(1), Page(s) 9 “Abortion ensuring access” by permission of the publisher. © 2006 Canadian Medical Association
Response to "Abortion: ensuring access"
Catherine Ferrier, MD, CCFP, FCFP
McGill University Health Centre (5 July , 2006 )
To the editor:
I would like to take exception to the Guest Editorial in this week’s issue of CMAJ (Abortion: ensuring access, CMAJ 175(1): July 4, 2006). . . women who are poor, young, immigrant, disabled and so on . . . have more difficulty accessing most health services . . .abortion has no unique status in this regard. As for the remarks about physicians who disagree with their position and do not refer all patients for abortion who request it, I can only say that they reflect an impoverished “one size fits all” understanding of physician integrity and the doctor-patient relationship.
“Response to "Abortion: ensuring access"” — eCMAJ
05-Jul-06 — In response to original article from, CMAJ 04-Jul-06;
175(1), Page(s) 9 “Abortion ensuring access” by permission of the
publisher. © 2006 Canadian Medical Association
Letter to the Editor, Canadian Medical Association Journal
10 July, 2006Professors Sanda Rodgers and Jocelyn Downie complain that “[s]ome physicians refuse to provide abortion services and refuse to provide women with information or referrals needed to find help elsewhere.” (CMAJ guest editorial, 4 July, 2006)
The authors almost (but not quite) assert that physicians opposed to abortion will “withhold a diagnosis,” “delay access,” “misdirect women,” and “provide punitive treatment.” They insert, in the midst of this list, the imaginary offence of “failing to provide appropriate referrals:” imaginary, because the Canadian Medical Association does not require referral for abortion, and none of the cases thus far proposed by some of the authors’ like-minded colleagues support such a claim.1 Nonetheless, they insist that all of these practices, refusal to refer among them, constitute malpractice and can lead to "lawsuits and disciplinary proceedings."
This passage does three remarkable things, all in one breath: it subtly impugns the integrity of objecting physicians; it associates conscientious objection with “punitive treatment” and other unethical practices; and it envelopes conscientious objection to abortion in an atmosphere of menace. It is a masterful symphony of accusatory innuendo, contrived connections, and strategic omissions. An unprepared reader may overlook the lyrical niceties, but the melody - “thou shalt refer or else” - is unmistakable.
Professors Rodgers and Downie stand in relation to their students and medical professionals as medical professionals stand to their patients, but their editorial fails to respect the principle of informed consent. On the contrary: it parallels the discreditable practice of securing the consent of a patient by manipulative and selective communication. It makes no difference that the consent sought in this case is to a proposition and outcomes favoured by the authors, rather than diagnosis and treatment favoured by a physician.
The authors are free to pursue their goal of increasing access to abortion, but they ought to do so without suppressing freedom of conscience in another profession. They are, after all, lawyers and law professors, not health care workers, and they will not hold in their own hands the products of the policies they seek to impose upon others.
Sean Murphy,
Administrator
Protection of Conscience Project
Notes:
1. Including Zimmer v. Ringrose
(1981), 124 Dominion Law Reports (3d) 215 (Alberta Court of Appeal);
Zimmer v. Ringrose (1978), 89 Dominion Law Reports (3d) 657 (Alberta
Supreme Court); McInerney v. MacDonald (1992), 93 Dominion Law
Reports (4th) 415 (Supreme Court of Canada); Malette v. Shulman
(1990), 67 DLR (4th) 321 (Ont. Court of Appeal); Nancy B v Hotel Dieu
de Quebec (1992), 86 DLR (4th) 385 (Quebec Superior Court); R. v.
Morgentaler (1988)1 S.C.R 95-96 (Supreme Court of Canada). See
Murphy, Sean,
Postscript for the Journal of Obstetrics and Gynaecology Canada:
Morgentaler vs. Professors Cook and Dickens.
June
Free speech for pharmacists
The
Oregonian
June 23, 2006
Reproduced with permission
Jonathan
Imbody
Senior Policy Analyst
Christian
Medical Association
The editorial, "Pushing back on 'morning-after' access" wrongly casts an unconscionable decision by the Oregon Board of Pharmacy as a valiant attempt to "push back against efforts to restrict access to the 'morning-after pill.'"
Newspaper editors may not recognize a drug's dangers, but they should readily recognize threats to our First Amendment freedoms--our rights of free speech and the right to freely exercise our religious beliefs.
If a state pharmacy board can force pharmacists to violate their own religious beliefs by filling or referring a prescription for a potential abortifacient like the “morning-after pill”, what meaning does religious freedom have?
If a pharmacy board can forbid pharmacists from what is snidely labeled "sermonizing to patients" about negative aspects of the pill, what meaning does free speech have? How does muzzling the pharmacist serve the interest of a patient who deserves full disclosure of all the facts?
Wherever one stands on the abortion debate, it should be clear that restricting the rights of free speech and free religious expression of one group of citizens represents a threat to all citizens. If we allow such selective abridgements of freedoms, we may wake up the next morning only to find our own rights stolen as well.
April
Guided By Conscience
News and Views
Christian Medical and Dental
Associations
6 April, 2006
Reproduced with permission
RedNova. March 28, 2006--Dr. Joanna Stacey, who has a small practice at Carilion Gynecology in Roanoke, has made a conscious decision never to perform an abortion. Salem oncologist William Fintel counsels about one patient a year against the idea of physician-assisted suicide. John Reuwer, an emergency room doctor at Carilion New River Valley Medical Center, said when women come in for emergency contraception -- even in the case of sexual assault -- and he is the only doctor on duty, he will refer the case to another doctor who has less of a problem dispensing what is commonly known as the morning-after pill. Stacey, Fintel and Reuwer are members of the Christian Medical & Dental Associations.
Faith and values, and their implications, are factors in emergency rooms, family practices, residency programs, hospital bioethics committees and operating rooms in the Roanoke and New River valleys. Issues of conscience are coming up increasingly as medical developments in reproductive technology and at the end of life raise ethical concerns. Some of the doctors interviewed for this story said they make decisions based on their conscience about issues such as emergency contraception, referrals for abortions and end-of-life care. But some people question whether patients are ill-served when health care providers make decisions based on their conscience.
The right of conscience has recently made headlines. Pharmacists in Illinois have sued Walgreens for firing them for not dispensing emergency contraception. Anesthesiologists in California have refused to participate in an execution. Should a health care provider decide not to treat a patient, however, a claim of abandonment could arise, according to a Roanoke attorney who specializes in health law. The question of whether future doctors plan to learn how to perform an abortion comes up early in their medical careers. Problems arise when patients have not made their wishes clear in legal documents such as advance directives and living wills.
"God first came up with this idea. Many Scriptures address the importance of conscience - weak and guilty versus good conscience. While we are reminded of the consequences (bad and good) of acting on consciences (weak and good), I could find nothing to suggesting that God would deny us that right.
"CMDA does not deny the right of conscience to its members. To become members, we sign a Statement of Faith saying that we agree on a few basic tenets of the Christian faith (e.g., Father, Son, Holy Spirit, and the Bible), but we are free to follow our conscience concerning the many positions taken by the Associations. Our most fundamental positions, the CMDA Ethical Statements (also called Standards for Life), are voted on by the representative bodies of the membership. Nevertheless, we are free to disagree and behave as such.
"But some in our society want to take away that right from those who provide healthcare. Two of the many dangers of doing this are highlighted by these questions: Do we really want to be cared for by doctors who are forbidden from standing by their convictions? Secondly, if society can take away this right from one class of citizens, who will be next?"
[Ref. Jen McCaffery. "Guided By Conscience." RedNova. March 28, 2006. Also "Guided By Conscience" in the Roanoake Times, 25 March, 2006]
March
Outlawing Conscience: Why We Need a Conscience Clause
BreakPoint
March 20, 2006
Printed with permission of
Prison Fellowship
Heather Williams spent five years working as a pharmacist at a Target store in St. Louis. During that time, Target accommodated Williams’s desire not to take part in dispensing the morning-after pill—the drug that causes the abortion of an embryonic human being. But then Planned Parenthood threatened to boycott the Target chain over Williams’s employment—so Target fired her.
Now, there are more than three hundred other pharmacies in St. Louis. So this was not a matter of great public concern. Pharmacists are not the only health-care providers under attack for obeying the demands of their conscience. Catholic hospitals are pressured to offer abortion services. And at some medical schools, students are told it’s not enough to learn how to remove a deceased fetus from a patient: They must also take part in the abortion of live fetuses—even though they are learning nothing new, because the procedure is identical. The reason? It’s indoctrination.
Now, here’s the great irony: These attacks on pharmacists are coming at the very time that the California Medical Association is attempting to bar doctors from getting involved in death-row executions—even if the doctors have no objections to taking part. You can’t kill murderers, but you must kill babies. Health-care providers, it appears, are allowed to have a conscience, so long as those consciences object only to politically correct moral evils.
Some observers, like the Washington Post, argue that the moral objections of pharmacists must be sacrificed if they interfere in medical decisions made between doctors and patients. This argument is both ethically confused and false. For every pharmacist who refuses to dispense the morning-after pill, there are hundreds who will. So what is really going on here?
What’s going on is an effort to silence any reminder, any public witness, that abortion is a moral evil, an offense against God. On some level, you see, abortion advocates know that killing unborn children is wrong. In Romans, Paul says that even the pagans know God’s moral law because it is “written on their hearts, their consciences also bearing witness.” Those who become incensed at the witness of people like Heather Williams are caught up in the age-old rebellion of the human race against its Creator. They cannot bear even the mention of the God whom they have rejected, or of His laws.
That is why it’s not enough for abortion promoters that the morning-after pill is legal and readily available. In order to live with their own consciences, they need unanimous assent that abortion is a moral good. And that means silencing those whose words and actions testify otherwise.
But freedom of conscience goes to the very heart our form of free government. This is why we need legislation to protect the rights of those who object to getting involved, not only in abortion, but in embryonic research, cloning, assisted suicide, and assisted reproduction.
You can find out what your own state needs to do to protect the conscience rights of health-care workers by visiting our BreakPoint website (www.breakpoint.org). And explain to your neighbors what’s really going on when abortion advocates try to shut down those who act out of conscience: Those who do are an uncomfortable reminder to others that they are violating the most basic laws of God and of human decency.
Comment:
The commentary refers to the morning-after pill as an abortifacient, without further qualification. The drug can prevent the implantation of an embryo and thus cause its death, which many objectors consider to be the moral equivalent of abortion. However, it can also act by preventing ovulation and by interfering with sperm transport so as to prevent conception, in which case it has a contraceptive rather than abortifacient effect. The distinction does not affect the principle espoused in the commentary - that freedom of conscience ought to be respected - nor the author's opinions about some of the reasons for opposition to freedom of conscience. [Administrator]
Letter to the Editor, Harford Courant
20 March, 2006Frances Kissling, who, for political purposes, purports to have some association with the Catholic Church, poses the rhetorical question, "Does Church doctrine trump rape victims’ needs?" (Hartford Courant, 19 March, 2006). The title of her column illustrates the old problem of getting the wrong answers by asking the wrong questions.
Catholics who are faithful to the teaching of their Church are not the only religious believers who object to the use of post-coital drugs or devices when it is possible that they may cause the death of an early embryo. Indeed, such objections could be made by avowed atheists or agnostics who believe, for non-religious reasons, that the existence of a human embryo is a factor to be considered along with the needs of a rape complainant. For conscientious objectors, the key point is not Catholic doctrine, but the possible presence of another human individual and the moral obligations added by that circumstance to their obligations to the complainant.
Ms. Kissling would have her readers believe that this is not an issue, citing unidentified "scientific and medical evidence" that what she calls emergency contraception "acts before a pregnancy occurs." Leaving aside the definition of ‘pregnancy,’ Ms. Kissling does not disclose that this statement involves at least one of two presumptions, one false, the other unexamined: that post-coital drugs and devices act only by preventing fertilization, and that the presence of an early embryo prior to implantation is of no moment in moral reasoning.
In fact, post-coital drugs like ‘Plan-B’ may not prevent fertilization, but may cause the death of an early embryo by altering the endometrium and preventing implantation.1 This is even more clearly so in the case of the copper Intrauterine Device (IUD),2 which is installed for so-called ‘emergency contraception’ up to five days after ovulation.3
Conscientious objection does not normally arise in cases involving rape complainants if it can be established that ovulation has not taken place or that fertilization has not occurred, because it is then unnecessary to consider the needs of an embryonic human individual in addition to the needs of the complainant. Only when conception may have occurred does a health care provider face the question: is one justified in deliberately or negligently killing the embryo at the request of the complainant?
This is a moral question forced upon us by scientific knowledge and medical capabilities. For Ms. Kissling, the answer is clearly, "Yes," and she expects all "decent people" to agree with her. Indeed, she is so confident of the infallibility of her moral judgement that she would impose it even on health care workers who disagree. This is a most peculiar position for someone who publishes a quarterly called Conscience and who claims to be an advocate for freedom of conscience.
Perhaps, in Ms. Kissling’s view, freedom of conscience belongs only to people who are decent enough to agree with her. A more generous and enlightened approach is preferable in a liberal democracy.
Sean Murphy, Administrator
Protection of Conscience Project
Notes
1. "Postcoital birth control pills ('morning after pills') may be prescribed in an emergency (e.g., following sexual abuse). Ovarian hormones (estrogen) taken in large doses within 72 hours after sexual intercourse usually prevent implantation of the blastocyst, probably by altering tubal motility, interfering with corpus luteum function, or causing abnormal changes in the endometrium. These hormones prevent implantation, not fertilization. Consequently, they should not be called contraceptive pills. Conception occurs but the blastocyst does not implant. It would be more appropriate to call them 'contraimplantation pills'. Because the term 'abortion' refers to a premature stoppage of a pregnancy, the term 'abortion' could be applied to such an early termination of pregnancy." Keith L. Moore and T.V.N. Persaud, The Developing Human: Clinically Oriented Embryology (6th ed.) Philadelphia: W.B. Saunders Company, 1998, p. 532. Quoted in A One-Act Drama: The Early Human Embryo:'Scientific' Myths and Scientific Facts: Implications for Ethics and Public Policy, Medicine and Human Dignity, note 23. "International Bioethics Conference, 'Conceiving the Embryo'"Centre Culturel, Woluwe-St. Pierre, Brussels, BelgiumSunday, October 20, 2002. Revised 23 October, 2002.
"The 2 most common types of hormonal EC used in the US are the Yuzpe regimen (high-dose ethinyl estradiol with high-dose levonorgestrel) and Plan B (high-dose levonorgestrel alone). Although both methods sometimes stop ovulation, they may also act by reducing the probability of implantation, due to their adverse effect on the endometrium (a postfertilization effect). The available evidence for a postfertilization effect is moderately strong, whether hormonal EC is used in the preovulatory, ovulatory, or postovulatory phase of the menstrual cycle." Kahlenborn, C, Stanford, JB , and Larimore, WL, Postfertilization Effect of Hormonal Emergency Contraception. The Annals of Pharmacotherapy: Vol. 36, No. 3, pp. 465–470. (Accessed 9 January, 2003). The findings are not uncontested. For example, see Marions L, Hultenby K, Lindell I, Sun X, Stabi B, Gemzell Danielsson K., "Emergency contraception with mifepristone and levonorgestrel: mechanism of action." Obstet Gynecol. 2002 Jul;100(1):65-71. PMID: 12100805.
"Plan B is believed to act . . . principally by preventing ovulation or fertilization (by altering tubal transport of sperm and/or ova). In addition, it may inhibit implantation (by altering the endometrium." Drugs.com Prescription Drug Information for Consumers and Professionals, PDR Drug Information for Plan B Tablets. (Accessed 2005-08-23)
2. "There are many varied mechanisms whereby IUDs exert their antifertility actions. Most of these mechanisms act simultaneously to achieve the desired effect. The following two sections present the principal contraceptive actions."
"Inflammatory reaction to foreign body. . . denatures endometrial enzymes, interferes with implantation of blastocysts and modifies endometrial metabolism of glycogen. Copper bearing IUDs. . . inflammatory response: qualitatively the same as with non-medicated IUDs. . . interferes with glycogen metabolism by endometrial cells; interferes with uptake of estrogen by endometrial cells; modifies content of DNA in endometrium. Progestin bearing IUDs: suppresses endometrium, impairs implantation of blastocysts." Connell, EF, Tatum, HJ, Women's Reproductive Health Care. Shaw, E. (Ed.) London, Ont.: Creative Infomatics, 1992, p. 94-953. Malleson, Roey M., Emergency contraception: A simple, safe, and effective approach to preventing pregnancy after unprotected intercourse or contraceptive failure. BC Medical Journal, Vol. 44, No. 1, January/February, 2002, p. 32-33
February
Heavy-handed in Massachusetts
Christian Medical Association commentary
The
Washington Times
18 February, 2006
Reproduced with permission
Jonathan Imbody
Senior Policy Analyst
Christian Medical Association
An imperious Massachusetts state pharmacy board dropped a bomb on private enterprise and individuals rights this week, ordering Wal-Mart to stock the controversial “morning-after pill” ("Wal-Mart to sell morning-after pill," Nation/Politics, Tuesday). The “morning-after pill” sometimes prevents pregnancy and can also end the life of a developing human embryo.
Massachusetts' move to expand abortion rights into abortion mandates further advances this curious campaign of "pro-choice" abortion advocates. “Morning-after pill” mandates snuff out the choice of businesses like Wal-Mart and of individual pharmacists, who apparently are expected to check their consciences at the pharmacy door.
One of the successful plaintiffs in the Massachusetts suit, Dr. Rebekah Gee, summed up her case by asserting, "My patients should not have to shop around." Abortion advocates have found yet another new right in the Constitution--the right not to have to shop around.
That would be news, of course, to the Massachusetts delegation to the Constitutional Convention in 1787. In an age of despotism, those revolutionary thinkers dared to declare that no one should be "deprived of life, liberty, or property, without due process of law; nor shall private property be taken for public use, without just compensation."
With its heavy-handed ruling, the state is poised to be hoisted by its own petard. Businesses eventually relocate when overburdened with crooked conditions of commerce. Individual pharmacists will take refuge in other states when they recognize that the ink seems to be fading on the Bill of Rights in Massachusetts.
CMA in Washington Post on Conscience Rights
Christian Medical and
Dental Associations
News & Views
2 February, 2006
Reproduced with permission
The Washington Post, Jan. 30, 2006--More than a dozen states are considering new laws to protect health workers who do not want to provide care that conflicts with their personal beliefs, a surge of legislation that reflects the intensifying tension between asserting individual religious values and defending patients' rights. About half of the proposals would shield pharmacists who refuse to fill prescriptions for birth control and "morning-after" pills because they believe the drugs cause abortions. But many are far broader measures that would shelter a doctor, nurse, aide, technician or other employee who objects to any therapy. That might include in-vitro fertilization, physician! -assisted suicide, embryonic stem cells and perhaps even providing treatment to gays and lesbians.
Because many legislatures have just convened, advocates on both sides are predicting that the number debating such proposals will increase. At least 18 states are already considering 36 bills. The flurry of political activity is being welcomed by conservative groups that consider it crucial to prevent health workers from being coerced into participating in care they find morally repugnant -- protecting their "right of conscience" or "right of refusal."
"This goes to the core of what it means to be an American," said David Stevens, executive director of the Christian Medical & Dental Associations. "Conscience is the most sacred of all property. Doctors, dentists, nurses and other health care workers should not be forced to violate their consciences.
The swell of propositions is raising alarm among advocates for abortion rights, family planning, AIDS prevention, the right to die, gays and lesbians, and others who see the push as the latest manifestation of the growing political power of social conservatives.
Just because we have taken a professional license doesn’t mean we must abandon our personal morality. If a physician can be forced to dispense an abortifacient or do IVF for a homosexual couple, then how can he or she refuse to perform an execution or euthanasia? If we stand by while the constitutional freedoms of pharmacists and other healthcare professionals are denied, there will be no one to stand with us when we are in the crosshairs.
I encourage you to speak out in your professional organizations and to your state government on this issue. We dare not lose this battle."
[Ref: Rob Stein. "Health Workers' Choice Debated: Proposals Back Right Not to Treat." The Washington Post January 30, 2006]