Paige Gerson was panicked. The 38-year-old divorced mother with two children had what she called a "whoops" moment of unprotected sex. "I was scared that I might be pregnant," she recounts of the 2005 incident. So she called the ob/gyn practice near Kansas City, Kansas, where she had been a patient for five years. It was 9 o’clock on a Saturday morning, and she reached the on-call ob/gyn. Gerson told the doctor what happened and asked what medicine she could take to ensure that she did not become pregnant. The physician replied coolly, "I cannot prescribe anything that would potentially prohibit a pregnancy from occurring."
Gerson went from panic to shock. "Is that because of your religious values?" she asked. The doctor just repeated her refusal, and said that another doctor would be on-call starting at 7 pm, but that doctor might respond the same way. Gerson asked her what medical options were available to her. The physician declined to discuss the matter further and suggested that Gerson go to an emergency room.
"If I go to a local ER in conservative Kansas, maybe the same thing will happen," she remembered thinking. Frantic, Gerson finally reached a friend who once worked for Planned Parenthood. That’s when she was first told about Plan B. If she took the emergency contraception within 72 hours of unprotected intercourse, it could prevent pregnancy.
Gerson later learned that half of the doctors at her ob/gyn practice were Catholic and objected to Plan B on religious grounds. Her odds of finding a physician in her practice to prescribe it on weekends were no better than 50 50. "When do most people have sex? On weekends, at night, when doctors’ offices are not open," she says. In 2006, the FDA finally approved Plan B for over-the-counter sales to women 18 and older, but the medication is kept behind the counter and must be dispensed by a pharmacist. Women’s groups are receiving numerous reports of pharmacists refusing to dispense the medication.
"It still makes me angry," says Gerson, two years later. "I was not a political person then, but I am now. It changed me."
Around the country, patients are increasingly encountering health-care providers who have religious objections to providing treatment, medication, or information regarding birth control, abortion, end-of-life care, and reproductive health, to name the most contentious issues. "Doctors should never participate in something that they have a moral objection to," says Gene Rudd, MD, the senior vice president of the Christian Medical and Dental Association (CMDA). But critics charge that mixing religion with medicine leaves patients unserved, untreated, and misinformed. As a result, lawsuits, complaints, and legislation are cropping up on both sides of the religious divide.
A key conflict that arises when religion and medicine intersect is the issue of informed consent. A study of 2,000 physicians in the United States published in the New England Journal of Medicine in February 2007 reported that "14 percent of patients - more than 40 million Americans - may be cared for by physicians who do not believe they are obligated to disclose information about medically available treatments they consider objectionable. In addition, 29 percent of patients - or nearly 100 million Americans - may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments." Physicians who identified themselves as religious were the most likely to raise objections and the least supportive of full disclosure.
The landmark study provoked a furious exchange of letters to the NEJM by physicians on both sides of the issue. "A philosophy that permits physicians’ rights to trump their obligations to patients is unconscionable," wrote University of Chicago professor Lainie F. Ross, MD, PhD, and Vanderbilt University professor Ellen W. Clayton, MD, JD.
Religious physicians defended their choices. "If we truly believe that a given procedure violates patients’ intrinsic human dignity, then our responsibility to our patients mandates that we not help them procure that procedure," wrote Patrick O’Connell, MD and Jacques Mistrot, MD from Raleigh, North Carolina.
The conflict is also occurring at an institutional level. About one in five hospital beds in this country is in a hospital that is affiliated with a religious entity, many of which disapprove of certain services. The Catholic Church, for example, has more than 500 affiliated hospitals, which typically have a prohibition on abortion, or anything that is construed as abortion. "In those hospitals, physicians [not necessarily subscribing to the beliefs of the institution but bound to practice within them] who are dedicated to providing comprehensive care for their patients are unable to do so because there are religious-based restrictions at the hospital," says Lois Uttley. She is the director of Mergerwatch, a New York City-based nonprofit organization that fights to protect patients’ rights and access to care from religiously based restrictions. "In that instance, you have both the physician and the patient being restricted in their ability to receive or provide good medical care."
When patients walk into the offices of Ruth Bolton, MD in Plymouth, Minnesota, they notice a difference. First, there are the Bibles in the waiting room and the exam rooms. There is a painting in the waiting room that depicts a family and physician all praying, with Jesus Christ standing behind them. "We have people who didn’t commit suicide because of that picture," says Bolton. "My patients say it represents a place of safety."
Bolton left her job teaching at the University of Minnesota Medical School to open a Christian medical practice in 1997. The Soteria Family Health Center - soteria is a Greek word that means "to heal" and "to save" - operated for a decade. Its mission statement included "sharing biblical health principles."
Bolton is part of a growing movement among physicians to integrate their religious and medical practices. The 18,000-member Christian Medical and Dental Association, which Rudd describes as a "Christian ministry to and for doctors," has tripled its membership in the last decade. Bolton is the president and chair of the CMDA board of trustees.
According to its mission statement, CMDA exists "to motivate, educate, and equip Christian physicians and dentists to glorify God," to "bring people to Christ," and to "speak out as the trusted voice on bioethics to our culture."
The medical and spiritual advice that Bolton gives are often connected. She counsels patients that their health status "could be changed if they lived a healthy lifestyle. If you are going to choose a lifestyle of an extramarital affair, or a homosexual lifestyle that is so riddled with HIV, it increases your potential for early death or bad illness in the future."
Bolton insists that Christian doctors fill a need within their communities. "There is a huge demand for pro-life doctors to be in one place. A lot of parents, if they bring their 13-year-old daughter in, would like you to teach them abstinence, rather than hand them condoms and tell them to practice safe sex."
When a patient has an unwanted pregnancy, "rarely do they come into our clinic asking for an abortion because it’s well known we don’t refer for abortions," she says. "They are usually just scared and they don’t know what to do. We try to make sure they know all the options, and explain that they have more choices than just having an abortion. They make up their own mind." Bolton will not recommend an abortion provider, but she says that "the patients know where to go to get them."
In spite of her strong religious beliefs, Bolton tries not to be judgmental. "I’m a doctor. If people come in and they are overweight, or a smoker, I don’t approve, but I treat them. Our job in this clinic is to care for their health, not to convert their beliefs. Most of us make choices in life, and we are not going to change that."
In May 2007, financial pressures forced Bolton and her fellow Christian physicians to sell Soteria to Fairview Health Services, a large not-for-profit health-care system. She worries what the change will mean. "They are trying to be morally neutral, but they probably will be taking down most of our religious art and taking out Bibles from the rooms."
Michael Rowland, MD is a Christian physician who runs an urgent-care clinic in Slidell, Louisiana. Patients might not notice anything different about his practice unless "they have some issue related to poor lifestyle choices, like drug abuse, or abortion." Instead of referring patients to a specialist for their problems, "I might refer to them to pastoral counseling or a 12-step program, which is widely recognized as keeping alcoholics from falling off the bandwagon."
"Listening to people and offering guidance - that’s the key," he says of his approach. So is a belief in God. "One survey showed that 80 percent of patients believe in God, but when they surveyed psychiatrists, 95 percent of them don’t, and a fairly high percentage of family practice doctors don’t believe in God." He insists, "Many people find it helpful to integrate God into their lifestyle. If they are going somewhere where they not getting spiritual guidance, then that’s an unmet need for them."
He recognizes that some patients are not interested in the spiritual guidance he offers - particularly since it comes laced with some strong value judgments. "Probably, most gays are not receptive to changing their lifestyle, regardless of the health implications. As far as addressing that lifestyle, you can approach it as a straight medical issue: You are sleeping around; you have an increased risk of HIV; and if you get HIV, there’s a good chance you’ll die."
"I believe that homosexuality is a choice," he continues. "There’s no gay gene that’s been found. If you look at some of the theories in psychiatry, they say maybe they had a distant father, or they didn’t bond with their mother. There is counseling where people had a homosexual lifestyle, and are now living heterosexually. If it were genetic, that wouldn’t happen. But most people who come to me, they’re not receptive to that." [The American Psychiatric Association, which does not consider homosexuality a mental disorder, has formally opposed "conversion therapy," declaring in 2000, "Recent publicized efforts to repathologize homosexuality by claiming that it can be cured are often guided not by rigorous scientific or psychiatric research, but sometimes by religious and political forces opposed to full civil rights for gay men and lesbians."]
Rowland, like Bolton, often prays with his patients. One such patient is Daniel Glover, 36, an arborist from Folsom, Louisiana, who was seriously injured in a fall from a tree and has endured multiple surgeries. Glover says, "I discussed with Dr. Rowland my spirituality. Once I found out he was a devout Christian, I asked him if he minded if I prayed. He obliges me. We stand up, hold hands, and I bow my head and I pray to my god."
"I think prayer can make a difference in people’s lives," says Rowland, "especially in situations where maybe there isn’t an answer medically."
Guadalupe Benitez was a 28-year old lesbian from Oceanside, California, who was eager to start a family with her partner. It was 1999, and after a year of unsuccessful attempts to become pregnant through artificial insemination, Benitez’s physician referred her to a fertility specialist. At her first visit, the specialist informed her that "it was against her religion to help a same-sex couple bring a life in the world," Benitez says. The doctor agreed to administer fertility drugs. But nine months later, following months of drug therapy and one operation, doctors at the ob/gyn practice declared that "they were Christian and they would not help a same-sex couple have a child." One physician told Benitez and her partner to find another doctor "like any normal couple."
"It was a shock to me," says Benitez, who works as a medical assistant. "I could not believe that he was saying ’we will not treat you because you are a homosexual.’" Benitez still fumes at the memory. "I didn’t come there because I was gay. I came there because I had a medical condition."
Months later, Benitez found another fertility specialist, and conceived a boy, and later twin girls. But her medical ordeal left her struggling with depression and led her to seek psychotherapy. In 2001, she decided to fight back. She filed suit, charging the fertility doctors with discrimination. The landmark case is now headed to the California Supreme Court.
"This is the first case that addresses the question of whether a physician or other medical provider can assert a religious objection to treating a particular type of patient," says Jenny Pizer, senior counsel with Lambda Legal, the firm which represents Benitez. "We have decided as a society that it is critically important that people not be turned away because of who they are, whether at a lunch counter or a doctor’s office."
Religious doctors insist there is a larger issue at stake. "We have a marketplace and patients have alternatives," says Rudd of CMDA. "We are weighing access and convenience issues against a doctor’s fundamental right to exercise their freedom of religion."
In Benitez’s case, her insurance only offered full coverage for her to see the specialist who ultimately refused to treat her. "The health-care marketplace in the 21st century is not an ideal world," says Uttley of Mergerwatch. "Patients have limited options as to where and from whom they can receive health care. So it is not uncommon to have a situation in which a patient does not have another choice. When that happens, the consequence of a physician’s desire to exercise their religious conscience is that the patient suffers from a lack of medical care."
Lainie F. Ross, MD, PhD, the associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, puts it more bluntly. "Individual physicians are allowed to make martyrs of themselves. They are not allowed to make martyrs of their patients."
Medical controversy is not necessarily bad for health care. "Patients are well served by physicians who conscientiously seek their patients’ good, and do so in a way that shows respect for patients in spite of disagreements, and that is candid about how a doctor’s convictions may or may not limit the sorts of practices they are willing to provide," says Farr Curlin, MD, of the University of Chicago, the lead author of the recent NEJM study of the role of religion and conscience in medical care.
But. Ross insists, "When you have a right of conscientious objection, rights have responsibilities. One responsibility is to refer a patient to another doctor. They can’t just refuse to do certain things."
For Benitez, becoming a mother was only the beginning of a larger struggle that was foist upon her. "I just want justice for all. I want to make sure this is not done to somebody else - for my children, for their children - that they will not be discriminated against. If you are going to provide services for one person, you have to provide them for all. If you can’t accept that, maybe you shouldn’t be in the medical field."
David Goodman is a journalist based in Vermont, and the author of six books, including the New York Times bestseller Static: Government Liars, Media Cheerleaders and the People Who Fight Back (Hyperion, 2006), which is due out in paperback this fall.