I Morally Object to Your Health Care

Ms. Nicole Arteaga’s story opened our eyes to something that is not infrequent, educating the masses that according to U.S. federal law health care providers have the right to refuse to provide health care if it is against their personal morals. I have encountered pharmacists who would not fill my patients’ prescriptions and I have worked with OB/Gyns who would not prescribe birth control under the protection of this law. There is an OB/Gyn at the University of Utah who will not give contraception to his unmarried patients. Do you think a law allowing pharmacists to refuse to fill Viagra prescriptions would ever come to pass? Yet when it comes to reproductive health care surrounding the uterus and people who have one, this is a perfectly reasonable approach to providing medical care. After all, we’ve been discriminating against women in health care for centuries, why stop now?

The “Church Amendments”(yes, that is their common name) protect health care providers (doctors, nurses, pharmacists, administration, etc) from being discriminated against if they refuse to participate in performing or assisting in performing an abortion or sterilization procedure that would be contrary to their religious beliefs or moral convictions. TL;DR: I can’t be discriminated against for providing sterilization or abortion care, my hospital can’t be denied grants/financial aid if it refuses to train in abortion or sterilization care, and I can’t be fired for not providing abortion or sterilization care if it is against my moral views.

A “Conscientious Objector” is someone who exercises the right to refuse to perform military service based on freedom of thought, conscience or religion. Essentially, someone in a position of lesser power has the right to refuse orders from someone in a position of greater power if the actions asked of them would violate their personal morals. It is clear how this works as applied to the military, however it has been argued that it cannot be applied to the medical field. The health care provider is in the position of greater power, and the patient is at their mercy. Thus, the “conscientious objection” cannot be applied lest it put the patient in danger.

I know what you’re thinking: “But no doctor (or nurse, pharmacist, etc) should be forced to do a procedure he or she is uncomfortable with,” and that is true. However, that statement is subject to underlying issues that have nothing to do with personal morals: training knowledge/skill, medical ethics, and evidence-based medicine. First of all, if I am not trained to do something (like a heart transplant), I am going to object to performing one based on the principle medical ethic “nonmaleficence.” Also, patients come to me all the time requesting procedures that I am uncomfortable performing because to perform them is not standard medical care as guided by evidence-based medicine. Just because someone “wants a hysterectomy” does not obligate me to provide one: a less invasive and safer procedure may result in the same outcome (eg, placing an IUD) and the patient must be informed of all options and risks (AKA informed consent). If I counsel someone that an IUD would be more appropriate than a hysterectomy, and I refuse to perform the hysterectomy, it is not due to personal beliefs or religious morals: it is because it goes against nonmaleficence and it may not be standard of care. I have training and knowledge that my patients do not have, and it is my job to inform them of all options and the risks involved with each. If they insist on a procedure that violates medical ethics and standard of care, I am then obligated to refer them to another physician.

Full disclosure: I conscientiously object to performing circumcisions. More accurately stated, I do not perform circumcisions due to lack of medical necessity and inability to obtain patient consent. My personal beliefs are not exercised in this decision. Instead, I utilize guidance from the core medical ethical principles and do not perform circumcision procedures.

I am morally opposed to smoking, but I would never refuse to treat someone for lung cancer because of my personal beliefs. If you are morally opposed to violence, you should not design military weapons. If you are morally opposed to eating meat, you should not be a butcher. If you cannot perform all of the duties of your profession, you should find a different profession.

Got IUD Questions? We Have Answers.

Recently, the amazing Robin Marty wrote a piece for Cosmopolitan entitled “12 Things Every Woman Should Know About IUDs” regarding some common questions about intrauterine devices. I was privileged and honored to have been asked to contribute. Here I have outlined the skeleton Q&A she and I went through but I encourage everyone to read the original piece in Cosmo. Also, you may want to follow @RobinMarty on Twitter because she does great work for reproductive health matters. Oh, and read the book she co-authored with @Hegemommy: Crow after Roe: How “Separate But Equal” Has Become the New Standard in Women’s Health and How We Can Change That.

Does insertion hurt (always, depends on dr, yes, but it goes away, etc?)

Insertion of an IUD will be different for everyone, depending on personal sensitivity and provider skill. The more honest the provider is with the patient regarding expectations, the better. I would never tell someone “it’s not bad” or “it won’t hurt.” Here’s what I tell my patients, more or less: “You’ll feel things that I’m doing, but I will tell you before I do anything. No surprises. There is a pinch, followed by 2 big cramps, and then it’s done. I do this a lot and it will be very quick, but at any point if you want me to stop, I will stop. You are in control.” Being open and honest about what they will feel often puts people more at ease, lessens any fear, and they are able to cope with the procedure better.


What happens if you keep an IUD in longer than you should?

There have been studies showing that IUDs can be effective past their expiration date so it is not dangerous that they stay in longer. However, out of concern of IUD failure and an unplanned pregnancy occurring I recommend removing and/or replacing the IUD before 2 years past its expiration date. There is no direct harm from the IUD by leaving it in longer, but the main concern would be it failing to protect against pregnancy.


Are there any disadvantages to removing it right away?

The only disadvantage of removing it right away that I can think of is missing out on an excellent form of contraception. There is an adjustment period to having an IUD, which varies from person to person. Again, if the health care provider sets up expectations appropriately I find that people are patient during the adjustment period and are more likely to keep their IUD.


Can you take it out yourself?

There are clinical trials under way looking at exactly that. There is no magic to removing an IUD: one pulls on the strings and it comes out. However, for someone to pull out their own IUD may be logistically difficult. Also, the strings may be difficult to grab and pull with sufficient force using only fingers. So, yes, it is possible, but it may be difficult.


There seem to be tons of side effects, are some more commonplace than others?

This depends on the IUD. For example, the copper IUD tends to make one’s periods heavier and crampier, but this is often alleviated with over-the-counter medication like ibuprofen. The hormonal IUD often makes one’s periods lighter, sometimes making them go away entirely, which is perfectly fine and has no health risks. This IUD may also help with endometriosis, though exactly how is not well understood yet. The hormone works locally on the uterus and cervix, but it may not help acne or hair growth if the person has issues with those things.


How often do people need to “shop” for a different brand?

Since there are only 2 types of IUDs, and one available form of each, once someone has decided which one they prefer there should not be a need to shop around. (Of note, there are 2 forms of the hormonal IUD, but the only difference is size and duration of use, not brand or method of action, or side effect profile.) 


Is it more painful to have it inserted/not as good of a form of birth control if you’ve never had a child?

I’ve placed IUDs in teenagers and adults who have never had children and I have noted as much variety in their experiences as I have placing IUDs in women who have had children. There is no difference in how well it works regarding whether or not the person has had children. There is no effect on future fertility after use is stopped. I tell my patients: “Once the IUD is removed, you go back to being as fertile as you ever were.” It’s an immediate return to their baseline fertility, which is different from other forms of contraception. (Of note: this is also true for the implant.)


I also direct my patients to bedsider.org for general information regarding different contraceptive methods. It’s a nice site to explore, especially if you’re uncertain which kind of contraception is the best method for you.