AMA Journal of Ethics^®

Case

Dr. Richard Ward is the only family practitioner in a small rural town where he has been practicing for 30 years. One morning 16-year-old Theresa Scholtz comes to Dr. Richard Ward's office alone. She does not have an appointment and tells the receptionist she will wait until Dr. Ward has time to see her. Dr. Ward has quite a few scheduled appointments that morning, so Theresa has to wait more than an hour before she can be seen.

The nurse finally takes Theresa back to an examination room, weighs her, takes her temperature and blood pressure and then asks the reason for her visit. Theresa looks nervous and ill at ease; she doesn't immediately answer.

Theresa doesn't look at the nurse but says quietly, "I am afraid I might be pregnant."

"So you are here to get a pregnancy test?" the nurse asks.

Theresa shakes her head, "No, I want Dr. Ward to give me the morning-after pill so I don't have to get a pregnancy test or have an abortion."

The nurse gets ready to leave, saying, "Dr. Ward will be in shortly."

When Dr. Ward comes into the exam room Theresa explains to him that she was out at a party, had a few too many drinks, and ended up having unprotected sex with her boyfriend. She says she is worried about the possibility of being pregnant and wants the Plan B® pill.

"I don't want to have a baby right now. I'm too young. I have to finish school," she says. "And I don't want to have to make a decision about an abortion. I want to just take this pill and move on."

Dr. Ward listens to Theresa's concerns and then says, "I understand why you are here. I have always had a policy of not performing abortions, and I won't start now by prescribing the morning-after pill. You can make an appointment with me in a couple of weeks for a pregnancy test to find out if you are pregnant. If you really want the morning-after pill I can give you the card of a physician I know in Gardendale who will see you."

"Gardendale?" Theresa says. "But Gardendale is 115 miles away. How will I get there without telling my parents why I am going? And how will I get there soon enough for the pill to work?"

Commentary 1

The most obvious, although not the only, ethical issue in this situation is the conflict between the principle of patient autonomy and the health care provider's right of conscience. Personal autonomy is one of the cardinal principles of modern medical ethics. It implies personal rule of the self that is free both from controlling interference by others and from personal limitations that prevent meaningful choice. Respect for patient autonomy, like all ethical principles, cannot be regarded as absolute and may at times be in conflict with other principles or other moral considerations. In this case such a conflict arises because the physician, Dr. Ward, is asked to provide care which he regards as potentially equivalent to performing an abortion—by prescribing Plan B®. It is generally accepted that a patient's right of autonomy does not trump the physician's parallel right to conscientiously abstain from a practice on religious or moral grounds provided that (1) the physician provides the patient information that would allow her to seek care with another health care provider who does not have such reservations and (2) the physician's refusal to treat does not endanger the patient's life or result in serious harm.

A meaningful resolution of ethical issues depends to a great extent on accurate clinical facts. Apparently, Dr. Ward knows that the effectiveness and probable mechanism of action of post-coital levonorgestrel 0.75 mg x 2, 12 hours apart (Plan B®) used for post-coital birth control depends upon the time the medication is taken in relationship to the time of ovulation. If taken before ovulation occurs, the effect is temporary delay of ovulation and interference with sperm penetration of the cervical mucous. If taken after fertilization has occurred, the effect might be prevention of implantation of a fertilized ovum, which is the basis for Dr. Ward's refusal to provide this medication. Evidence suggests that the effect on ovulation and on sperm penetration of ova are the predominant mechanisms of action. We are not told when, in relationship to the office visit, Theresa had unprotected sex with her boyfriend, nor is information given about Theresa's menstrual cycle, facts that might provide Dr. Ward a basis for modifying his advice to Theresa. For any particular patient, however, it is difficult to ensure that the medication is being given before fertilization has occurred.

Evidence also indicates that post-coital steroids, by reducing the risk of conception, actually decrease the incidence of induced abortion of clinically apparent pregnancies. Therefore, a physician who opposes abortion for religious or moral reasons must decide whether the use of a medication that occasionally prevents the implantation of a fertilized ovum but decreases the number of abortions overall is an acceptable moral and ethical tradeoff.

Ideally, Theresa's decision to use Plan B® should be made after she has received as much information about the drug as she is capable of understanding. Most importantly, she should understand that post-coital steroids are not 100 percent effective in preventing pregnancy, regardless of when the medication is taken. Even if Dr. Ward were to prescribe the medication, a follow-up visit might be necessary if there were subsequent symptoms or signs of an ongoing pregnancy.

Another important ethical issue is to what extent Dr. Ward's conscientious objection to providing Plan B® for Theresa should be affected by the distance she must travel (115 miles) to reach the nearest physician who will prescribe the medication. And what of Theresa's claim to have no transportation unless she informs her parents, which she does not want to do?

Importantly, Dr. Ward's refusal to provide the prescription for Plan B® is not a threat to Theresa's life. Furthermore, Dr. Ward has offered to provide follow-up, and he would, presumably, be willing to refer her to a colleague if pregnancy were diagnosed. A physician's ethical responsibilities do not extend to solving all social and domestic difficulties of every patient. In other words, short of a life-threatening emergency, he is not obliged to drive her to Gardendale. It is, nevertheless, Dr. Ward's responsibility to advise Theresa about reasonable options, such as confiding in her parents or enlisting the aid of her boyfriend.

As noted above, Dr. Ward should fully inform patients about circumstances in which he cannot provide care on moral or religious grounds, and this information should be readily available in time for patients to seek alternative care. Inasmuch as Dr. Ward is the only physician in a small town, it is likely that his personal position against induced abortion is well known in the community. However, patients in general and Theresa in particular may have no knowledge that Plan B® might in some instances act as an abortifacient. Then too, a physician should be consistent in his or her conscientious objection. To be ethically and morally consistent, a physician who objects to the use of post-coital steroids on the grounds that their effect in some cases may be to prevent implantation of the fertilized ovum should also object to the use of other forms of steroid contraception (eg, birth control pills) that affect the endometrium in ways that can prevent implantation.

Finally, two other important ethical dimensions illumine this encounter between Dr. Ward and Theresa Scholtz: beneficence, the physician's obligation to promote the well-being of the patient; and confidentiality, the responsibility not to divulge information to a third party. As regards beneficence, Theresa Scholtz has engaged in self-destructive behavior (binge drinking and unprotected sex). Simply providing her with a prescription for Plan B® without giving some attention to this behavior is not in her best interest nor does it contribute to her overall well-being. Dr. Ward's beneficence-based responsibility, at the very least, requires that he counsel Theresa about the dangers of her recent behavior and the possible benefits of confiding in her family.

As regards confidentiality, Theresa at age 16 is a minor. In most situations, physicians do not treat minors in nonemergent circumstances without the consent of a parent or guardian. Many state laws, however, protect adolescent confidentiality regarding diagnosis and treatment of sexually transmitted diseases, contraceptive counseling, and pregnancy. Dr. Ward probably knows almost everyone in town and is aware of their physical and emotional ailments and their socio-domestic circumstances. In a small community, the close relationship of the sole family physician with his patients does not diminish his ethical responsibilities, and it may complicate and intensify them.

In the future it is possible that Dr. Ward and other physicians will not be confronted with the necessity of prescribing Plan B® or similar medications, if the FDA approves these medications for nonprescription (over-the-counter) availability. The risks and benefits of such a decision are currently being debated.