44. Conscientious Objection By Primary Care Trainee And Faculty Physicians In An Appalachian Health Care System

Abstract

Refusal to provide medically appropriate care due to strongly held religious or moral beliefs, often called “conscientious objection,” is controversial. The refusal impacts reproductive health and care for gender minorities. This can be particularly restrictive for adolescents and young adults who may have limited access to care, and where the balance of power in the physician-patient relationship may be more pronounced. This study aimed to characterize primary care physicians’ objections to medically appropriate care in a single academic medical center and identify if these objections were associated with religiosity or level of training. A 17-question survey, partially based on preexisting instruments, was distributed to the resident and faculty physicians practicing in primary care at an academic institution in Appalachia providing care to a rural and medically underserved population. An investigator-designed religiosity score was calculated using six questions about religious beliefs and practices. Descriptive statistics were calculated to characterize the sample; χ2 and Fisher exact tests assessed for differences in religious objections to specific types of medical care by religious beliefs and training level. A total of 119 physicians participated in the survey (50% trainees). Half were female and the majority identified their training as internal medicine (45%) or pediatrics (23%). The majority identified as being Catholic, Christian, or Protestant, (29%, 22%, 11%, respectively), while 18% indicated having no religious affiliation. Most (66%) identified as white. Using the calculated religiosity score, 42% were “highly religious,” 37% were “moderately religious,” and 21% were “minimally religious.” Compared to 0% of the “minimally” or “moderately” religious participants, 17% of those who were “highly religious” had an objection to prescribing emergency contraception to adults (p<.01) and adolescents (with and without parental knowledge p<.01, respectively). One in five of “highly religious” participants objected to prescribing cross sex hormones to transgender adults (p=0.01) and transgender adolescents (p<.01) compared to 0-2% objection from “minimally” and “moderately” religious participants. Being classified as “highly religious” was also associated with objecting to all presented scenarios for abortion (including <20 weeks gestation, following sexual assault, and in a minor with parental notification) (all p<0.0001). Significantly more trainees than faculty physicians were undecided about telling patients upon establishing care if they had religious or moral objections to medically indicated treatments (24% versus 5%, p=0.03), and to not feel obligated to explain their objections (58% versus 30%, p=0.01). Most physicians felt they had an obligation to present all options for treatment (96%) and to refer to a colleague willing to provide treatments to which they objected (95%). This study suggests a strong link between personal religiosity and conscientious objection in clinical practice. Nearly all study participants felt there was an ethical obligation to present all options and refer to another willing provider; this proportion was slightly larger than previous studies. The prevalence of conscientious objection continues to be of concern, particularly in rural and medically underserved areas where adolescents, young adults, and others with limited access may be denied medically appropriate care due to lack of willing providers.