Bill Toffler objects.

He objects to abortion, the “morning after” pill and physician-assisted suicide. As a matter of personal conscience, he will not be involved in any of the three.

What makes Toffler controversial is that, in his work as a family medicine physician at Oregon Health & Science University Hospital [OHSU], he regularly has patients ask him to help them with all three. But he doesn’t, and he won’t.

OHSU Professor Bill Toffler, MD, objects to abortion, the “morning after” pill and physician-assisted suicide. As a matter of personal conscience, he will not be involved in any of the three.

“I will go to jail before I will do that,” Toffler said. “I will not aid and abet knowingly someone who wants to do something outside my practice boundaries.”

But Toffler, also a professor at the OHSU School of Medicine, does not practice in a vacuum. His patients also have rights. And sometimes, rights come in conflict.

Last year, OHSU’s institutional ethics committee took on the task of revising a little-known part of its policy manual — the part dealing with medical “conscientious objectors.” The policy manual details guidelines to allow OHSU medical professionals to follow their personal convictions about medical procedures without compromising patient care. The policy also governs how OHSU might discipline professionals who don’t follow the guidelines.

The committee finished its work in September. But physicians such as Toffler make sure the debate over conscientious objection continues. Toffler’s convictions are compelling him to violate OHSU’s “conscientious objector” policies.

Gary Chiodo, director of OHSU’s Integrity Office, served as chairman of the committee that revised the conscientious objection policy. He said the policy is an attempt to offer guidance to employees who might find their consciences in conflict with their work.

“You need to draw some lines so you know what’s permitted and what’s not permitted,” Chiodo said.
The 12-member OHSU ethics committee met every two weeks through spring and summer of 2005 and interviewed dozens of health care providers from different specialties. They were updating a policy that was formed through a similar process about 10 years ago.

Then, the policy formulation was in response to a newly adopted assisted suicide law, and the concerns of physicians, nurses and pharmacists who knew they did not want to participate, according to Susan Tolle, director of the OHSU Center for Ethics in Health Care. That original document also talked about abortion and end-of-life issues, such as removing life support.

‘Providers have a monopoly’
 
OHSU’s policy on conscientious objectors focuses on a couple of fundamental principles. OHSU employees will not be required to participate in procedures that come in conflict with their own beliefs.

But even conscientious objectors cannot refuse “indirect involvement” in procedures, according to the policy. Indirect involvement can include necessary care and comfort that patients may require, and also referring patients to other practitioners. And that just happens to be where Bill Toffler draws his line.

“Providers have a monopoly,” Chiodo said. “The patient can’t go to some other profession and get this. If a patient requests medical service, the policy says you don’t have to be directly involved in delivering it, but you do have to refer the patient to somebody else.” That, it appears, is where OHSU draws its line.

Nancy Berlinger, deputy director of the Hastings Center, a New-York based bioethics research center, called the OHSU policy admirable. Berlinger said the idea of conscientious objection in health care is gaining attention because of the changes in health care.

“There’s definitely more than 30 years ago,” she said. “When abortion was not legal you didn’t need a conscience clause about it. Once it became legal, then you saw the uptick about conscience clauses. When you have new procedures you have new conscience clauses.”

Conscience clauses are laws that allow health care professionals to abstain from procedures they find objectionable. An example is a law enacted in Wisconsin that protects lab workers who object to working with stem cells.

As new medical procedures are created at an accelerated rate, Berlinger said, new ethical dilemmas face people who practice health care.

“There are more concrete things you could object to,” she said. “A doctor can’t object to involvement in end-of-life because everybody dies. But because of different technologies that are part of end-of-life care, the goal posts keep shifting.”

Medical literature is full of case histories where conscience has come into conflict with practice. Fertility doctors and nurses may feel uneasy harvesting extra eggs and embryos. Neonatal intensive care nurses may object to severely impaired premature babies being kept on life support. Some states have found it difficult to find physicians willing to carry out capital punishment lethal injections.

But as far as Toffler is concerned, even as the technologies change, the fundamental questions remain pretty much the same.

“I’ve always had a sense that some practices were not something I personally wanted to do,” he said. He recalled watching students perform abortions when he was in medical school, and participating in one himself.
“I didn’t have the courage to speak up and say, ‘I don’t want to be involved in that.’ I watched a resident perform one and my eager beaver colleague said, ‘Could I do one?’ and I probably had a thousand thoughts flash through my mind, such as, ‘The woman’s going to have it done whether I do it or not;’ ‘the two people who have just done the procedure before me had no compunction about it and I don’t want to be offensive to them.’ So I acceded to the subtle pressure to conform.”

And he’s passing on what he has learned. Toffler said he teaches his medical school students to question everything they do from a personal moral standpoint.

A choice with consequences?

Now, Toffler said, nothing will make him refer those cases to another physician, though he’s begun to hear of complaints made to his dean about his unwillingness to provide services.

He said he has had a visit from an OHSU administrator who brought up his unwillingness to refer a woman patient to another provider, as required by the conscientious objection policy. He also has been asked to post signs in his office about the procedures he won’t perform. He refused, and considers the request a form of discrimination.

But it is the conscientious objector policy on indirect care — a physician’s duty to refer patients — that has Toffler perplexed, and a little concerned about his job. “I cannot believe the (ethics committee) believes it is ethical to refer someone for something that you believe is unethical,” he said.

Yet that’s how the conscientious objection policy reads. According to ethics committee chairman Chiodo, “It’s OHSU policy and it is adopted at the highest level.” Chiodo said he expects high level administrative discussions about any OHSU employee who disregards the policy.

Bioethics researcher Berlinger doesn’t offer any hard and fast rules in the dispute between Toffler and the OHSU policy. “It isn’t just about absolute rights to do or not to do,” she said. In fact, Berlinger said, the concept of organizational ethics is relatively new. But it’s at the heart of the OHSU rules.

“You’re saying an organization itself as an ethical enterprise needs to figure out how this piece fits,” she said. “It isn’t just a matter of individual rights.”

Morning-after’ pill prescriptions stir debate

Oregon Health & Science University’s new policy on health care providers who refuse to participate in medical procedures to which they morally object includes one notable addition. But that added procedure is a controversial one.

Nationally, a number of pharmacists have come under scrutiny for refusing to fill prescriptions for what is commonly called the “morning after” pill, which stops pregnancy after unprotected intercourse. And, according to Michele Stranger Hunter, executive director of National Abortion Rights Action League Pro-Choice Oregon, some Oregon pharmacists are acting in ways that may exceed the usual limits of conscientious objection.

Hunter said that in the last eight months women have called her to report pharmacists who not only refused to dispense the medication, but who confiscated the slip of paper on which the prescription was written. “I personally have heard that six times,” Hunter said. And she thinks such actions should not be allowed.

“If they’re literally withholding a piece of paper, they’re doing more than simply conscientious objecting,” Hunter said. “Now they’re stepping in the way. Now they’re putting themselves into an active role as barrier.”

Last fall, Hunter addressed the Oregon State Board of Pharmacy about her concerns. “We’re looking for them to promulgate a ruling that would ask that seamless access be ensured,” Hunter said. Seamless access, she explained, means that someone at the pharmacy fills the prescription — if not an objecting pharmacist, then another pharmacist who takes over.

Gary Schnabel, executive director of the board of pharmacy, said the board expects pharmacists to provide the type of service Hunter wants. “If they’re not going to do it they have to somehow make arrangements for somebody else to do it,” he said.

As for Hunter’s contention that some pharmacists are appropriating prescriptions, Schnabel said the board has not received any formal complaints about it, from Hunter or anyone else. If the board did find a pharmacist refusing to return a prescription slip to a customer, Schnabel said, that pharmacist would be disciplined. “The board would say that is unprofessional conduct,” he said.

Schnabel said he recognizes that some pharmacists feel strongly about both emergency contraception and RU-486, a drug that is taken to end a pregnancy after egg implantation has occurred. “It’s not an easy issue,” he said. “It’s emotional and action-packed.”

The problem is potentially worse in small towns, Hunter said, where there may be only one pharmacist and a client may not have an alternative.

“If it’s a single pharmacy in a rural area, that single pharmacy would need to figure out a way to fill that prescription,” she said.

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