March 2, 2008 12:36 PM
FOR IMMEDIATE RELEASE CONTACT: John Brehany, Ph.D., S.T.L.
February 29, 2008 Executive Director & Ethicist
Catholic Medical Association
215-877-9099; brehany@cathmed.org
CMA Calls for American College of Obstetricians and Gynecologists to Rescind
Ethics Opinion
DATELINE February 29, 2008 – The Catholic Medical Association (CMA) has called
upon the American College of Obstetricians and Gynecologists (ACOG) to rescind an
“ethics opinion” released last November by its Committee on Ethics. ACOG’s opinion
demands that ob-gyns opposed to abortion provide referrals for, and even perform,
abortions in certain situations, despite their conscientious belief that abortion involves the
killing of an unborn child. In a letter to ACOG president Kenneth Noller, M.D., CMA’s
president, Kathleen M. Raviele, M.D., F.A.C.O.G., said that the ethics opinion suffered
from substantial flaws in ethical analysis; created guidelines that were too vague and
contentious to be effective; and proposed solutions that were unjust, unworkable, and
harmful to the profession of medicine.
ACOG’s ethics opinion, titled “The Limits of Conscientious Refusal in
Reproductive Medicine,” came as a surprise to many ob-gyn doctors, since there was no
consultation among or vote taken of ACOG members prior to its release on November 7,
2007. “I was stunned when it came out,” said Lester Ruppersberger, D.O., a Fellow of
the American College of Obstetricians and Gynecologists. “This is an important and
complex topic. To spring this flawed mandate on the membership of ACOG and the
public is unfair and outrageous.”
According to Dr. Raviele, there are several fatal flaws in the opinion. “But what
is new and what is worst,” she explained, “is the opinion’s demand that all physicians
refer for and perform abortions.” “The committee that wrote this opinion shows no
respect for the beliefs of others. They have moved from believing that abortion should be
legal to defining it as ‘standard care’ under reproductive services. If physicians refuse to
go along with these demands they risk having an ethics complaint filed against them, and
this could cause them to lose their certification through the American Board of Obstetrics
and Gynecology. Because hospitals use board certification to grant hospital privileges,
pro-life physicians could lose their ability to admit patients to hospitals.”
CMA’s Executive Director, John F. Brehany, Ph.D., pointed out that ACOG’s
ethics committee is trying to exert a high level of control over physicians. “The opinion
actually discourages physicians from exercising ethical judgment in daily practice; it tells
them that this is a job for professional organizations,” Brehany noted. “Moreover, the
opinion suggests that physicians need ‘scripting’ to explain issues to patients. It says that
doctors must employ ‘professionally accepted characterizations of reproductive
services’.”
The CMA urged ACOG’s Committee on Ethics to rescind its opinion when the
committee meets March 17-18. The CMA urges physicians, their patients, and members
of the public to contact ACOG at their headquarters, to protest this denial of conscience
rights and religious freedom.
CMA’s letter to ACOG can be read in its entirety at www.cathmed.org.
The Catholic Medical Association is the nation’s largest professional organization
of Catholic physicians. More information on the CMA can be found at
www.cathmed.org.
BOARD OFFICERS
President
Kathleen M. Raviele, M.D.
President-Elect
Louis C. Breschi, M.D.
Vice President
Leonard P. Rybak, M.D., Ph.D.
Treasurer
Jan R. Hemstad, M.D.
Secretary
Maricela P. Moffitt, M.D., M.P.H.
EXECUTIVE DIRECTOR
John F. Brehany, Ph.D., S.T.L.
BOARD MEMBERS
Immediate Past President
Robert J. Saxer, M.D.
Past President
Thomas M. Pitre, M.D.
Regional Director Representatives
Paul J. Braaton, M.D.
John I. Lane, M.D.
Episcopal Advisor
Most Rev. Robert F. Vasa, J.C.L., D.D.
Chaplain
Rev. James R. Gould
Parliamentarian
Louis C. Breschi, M.D.
Executive Editor, Linacre Quarterly
Eugene F. Diamond, M.D.
FIAMC Representative
Kevin Murrell, M.D.
Consultants to the President
Clement P. Cunningham, M.D.
George Isajiw, M.D.
R. Steven White, M.D.
333 E. LANCASTER AVENUE, #348 • WYNNEWOOD, PA 19096-1929 • phone 215.877.9099 • fax 215.701.6577 • info@cathmed.org
Kenneth L. Noller, M.D.
Board President
American College of Obstetricians and Gynecologists
409 12th St., S.W.
Washington, D.C. 20090-6920
February 28, 2008
Dear Dr. Noller:
On November 7, 2007, the American College of Obstetricians and
Gynecologists (ACOG) Committee on Ethics released an Opinion, “The
Limits of Conscientious Refusal in Reproductive Medicine” (the
“Opinion”), which attempts to resolve the issue of ethically appropriate
limits of conscientious judgments in reproductive medicine. This is an
issue that demands serious attention and sustained dialogue.
Unfortunately, however, the Opinion not only fails to provide helpful
guidance, but is so flawed that it threatens the reputation of ACOG itself.
The Catholic Medical Association urges ACOG to rescind this opinion
immediately.
The Committee on Ethics’ Opinion exhibits three fatal flaws: (1) it is
woefully inadequate in basic ethical theory and analysis; (2) the
“considerations” advanced to limit conscientious judgments are so vague
and contentious that they cannot meaningfully function as ethical or
professional guidelines; and (3) the solutions proposed are unjust,
unworkable, and harmful to the profession of medicine. We elaborate on
these points briefly below.
1. Flaws in Ethical Analysis. The Opinion contains a seriously flawed
and gratuitously condescending approach to conscience. The Opinion
describes conscience in limited, negative, emotional terms, emphasizing
such terms as “private,” “sanction,” “sentiment,” and emotions such as
self-hatred. At best, the Opinion notes, “Personal conscience, so
conceived, is not merely a source of potential conflict.” In fact, however,
while conscience is a personal, subjective judgment, it is not merely
“private” or relativistic. Conscientious judgments provide guidance both
for good actions that should be done and unethical actions that should be
refused. It is true that conscientious judgments are at times accompanied
by emotion, particularly in conflict cases. Still, conscience is not a matter
of feeling, as the Opinion suggests, but a judgment about moral truth.
Upholding the Principles of the Catholic Faith in the Science and Practice of Medicine
C atholic M edical A s soci at ion
In addition to providing an inadequate description of the nature and role of
conscience, the Opinion fails to do justice to the ethical issue of
cooperation in evil raised by providing referrals for abortion and, indeed,
dismisses concerns about complicity in gravely immoral actions.
This disregard for the harm caused by complicity in moral evil is
particularly hard to understand given the painful lessons the medical
profession learned from physicians’ silent tolerance of, or complicity in,
the crimes against humanity in Nazi Germany. Here in the United States,
in the infamous Tuskegee Syphilis Study, U.S. Public Health Service
physicians denied treatment to patients with syphilis so they could study
the late stages of the disease. Moreover, physicians participated or
acquiesced in involuntary sterilizations under color of law in more than 30
more states between 1907 and the early 1970s. All agree now that these
practices were unethical and a violation of patients’ rights and that
physicians were wrong to cooperate, even tacitly, or to remain silent, even
when they were not direct participants.
The Opinion mentions, but fails to describe, what it means by the “set of
moral values – and duties – that are central to medical practice.” Since the
Opinion goes on to list four “criteria” that ostensibly trump physicians’
ethical convictions, it appears that these are the moral values and duties
the Ethics Committee has in mind. Inexplicably missing in this section of
the Opinion is any mention of respect for human life, which has been
recognized by most physicians across centuries and cultures as a
fundamental value and duty that is central to the practice of medicine.
Finally, the Opinion attempts, in several ways, to legitimize a moral duty
to provide any requested “reproductive service.” The Opinion appeals to
terminology such as “standard care,” “standard reproductive services,” and
“standard practices” without ever defining who or what has established
these standards. The Opinion attempts to conflate the duty to provide
treatment in an emergency with a new obligation – to provide “medically
indicated and requested care” where failure to do so “might” negatively
affect a patient’s “mental health.” This so-called obligation is unnecessary
and completely unfounded. Our position is that elective abortion is not
healthcare, nor does it qualify as an emergency. In a true emergency,
where a pregnant woman’s life is in danger, physicians can and should
strive to save the lives of the mother and her unborn child.
2. Considerations Limiting Conscientious Refusal. The “considerations”
that the Opinion claims limit conscientious judgments are so vague and
contentious that they cannot meaningfully function as ethical guidelines.
For example, the Opinion cites the “degree of imposition” as a criterion
for overriding the ethical and professional judgment of physicians. It is
not clear at all what kinds or degrees of “imposition” will trump ethical
judgment, much less why they should. In appealing to the criterion of
“effect on patient health,” the Opinion unfairly assumes that all requested
reproductive interventions (including abortion or egg harvesting) are in
fact good for the patient’s health. Moreover, it unfairly implies that
physicians with ethical objections to such practices are not motivated
precisely by concern for the patient’s short and long term health. In
appealing to the category of scientific integrity, the Opinion overstates the
certainty that current science can provide about the mechanism of drugs
(such as those used in Plan B). And it fails to recognize that the real
“possibility of postfertilization events” inherent in the use of such drugs is
a valid matter for a professional’s clinical and ethical judgment. Finally,
in appealing to “matters of oppression,” the Opinion injects a dubious
political criterion into the heart of medical decision-making.
3. Solutions Proposed. The Opinion proposes solutions that are unjust,
unworkable, and harmful to the profession of medicine. The Opinion
unfairly dictates that only physicians who oppose a specific set of medical
“services” should be required to provide patients with “prior notice of
their personal moral commitments.” We think that all physicians should
be ready to explain, whenever appropriate, their ethical convictions with
regard to medical practice and care. To suggest that providers with prolife
ethical convictions “practice in proximity to individuals who do not
share their views” is unworkable.
The solutions proposed in the Opinion are not only unjust and unworkable,
but harmful to the profession of medicine. First, by negatively and
narrowly defining conscience and by suggesting that judgments of
conscience are best left to “organized advocacy” groups, the Opinion
tacitly discourages physicians from thinking and acting in accordance with
their judgment of what is ethical or unethical. The demand that physicians
provide “professionally accepted characterizations of reproductive health
services” shows distrust of professionals and of the quality of the medical
profession as a whole. Second, in appealing to the vague criterion of past
discrimination allegedly suffered by some people, the Opinion allows
values and considerations extraneous to the practice and profession of
medicine to dictate treatment modalities.
Third, the Opinion invites lawmakers to enforce compliance with these
vague and contentious notions. This would run counter to AMA Code of
Ethics Opinion E-10.05: “[I]t may be ethically permissible for physicians
to decline a potential patient when . . . [a] specific treatment sought by an
individual is incompatible with the physician’s personal, religious, or
moral beliefs.” Moreover, this expressly contradicts ACOG’s own
Statement of Policy on Abortion: “The intervention of legislative bodies
into medical decision making is inappropriate, ill-advised and dangerous.”
Such legislation could not help but undermine the freedom and integrity of
the profession of medicine and invite additional litigation and legislation
that have nothing to do with promoting the health of women. Indeed,
ACOG should be aware that legislation attempting to enforce this Opinion
would violate constitutional and statutory protections of physicians’
freedom of religion and conscience rights at federal and state levels.
Finally, driving out physicians who respect the value of every human life
– born and unborn – from the profession of obstetrics and gynecology
would harm the profession and the health of many women and children.
There is a great deal of work to be done in assisting members of ACOG to
practice medicine conscientiously, and to educate patients on what this
means and why it is important. We stand ready to assist in this task.
However, to be valid, any effort will have to be based on sound ethical
analysis, undertaken in a spirit of dialogue, with respect for diversity in
beliefs. The Committee on Ethics Opinion No. 385 falls significantly
short in all these respects. Therefore, it should be rescinded immediately.
Respectfully,
Kathleen M. Raviele, M.D., F.A.C.O.G.
President, Catholic Medical Association
John F. Brehany, Ph.D.
Executive Director, Catholic Medical Association
cc.:
Anne D. Lyerly, M.D.
Chair, ACOG Committee on Ethics
Hal C. Lawrence, III, M.D.
c/o ACOG Ethics Committee
Ms. Mary Mitchell
c/o ACOG Ethics Committee
