Monday, 6 May 2013

Doctors should not be forced to provide emergency contraception if they have an ethical objection to it

The Independent has run the story of a ‘Christian-run NHS GP surgery’ which has apparently ‘attracted criticism for posting a notice warning that some of its doctors refuse to prescribe the morning-after pill to patients on grounds of conscience’.

The message on the door of The Links Medical Practice in Mottingham, south London advises patients that if ‘a consenting doctor is not available’ to prescribe contraception they should contact a local clinic or chemist.

One of the practice’s patients was apparently so outraged by this that she opted to leave the practice and Audrey Simpson, chief executive of the Family Planning Association, has said that other women should also think about leaving the surgery in response to the notice.

She is reported as saying: ‘Leaving will send out a message to them that women have the right to access emergency contraception.’

Women can of course legally access ‘emergency contraception’ in the UK and can buy the ‘morning-after pill’ levonelle over the counter without prescription from most pharmacies as well as accessing it free on prescription, from sexual health clinics and from NHS walk in centres.

But according to General Medical Council guidelines published just recently (see my full review of them here), doctors can also refuse to prescribe certain treatments as a matter of conscience.

The Guidance ‘Personal Beliefs and Medical Practice’ states:

‘You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients.’

It goes on to describe how this is to be done:

‘If, having taken account of your legal and ethical obligations, you wish to exercise a conscientious objection to particular services or procedures, you must do your best to make sure that patients who may consult you about it are aware of your objection in advance. You can do this by making sure that any printed material about your practice and the services you provide explains if there are any services you will not normally provide because of a conscientious objection.’

This seems to be exactly what these doctors have done.

The guidance adds that doctors who do not provide a certain treatment should ‘tell the patient’, tell them ‘that they have a right to discuss their condition and the options for treatment with another practitioner’ and ‘make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you’.

Why might doctors have an objection to prescribing ‘emergency contraception’?

There are three main reasons.

Some doctors may have an objection to prescribing contraception in principle. Many Catholics take this view.

Some doctors object to prescribing a drug which might in some circumstances act by preventing an early embryo from implanting in the womb as they see this as an early form of abortion. Although there is not firm proof that levonelle acts in this way there is at very least a degree of uncertainty and no absolute proof that it does not (more on this here – note levonelle in the UK is the same drug as Plan B in the US).

Finally some object because they are unconvinced that levonelle is an effective intervention. Its success rate is relatively low (95% within 24 hours of sexual intercourse, 85% from 25-48 hours and 58% from 49-72 hours).  Also in clinical trials its ready availability has been shown not to reduce pregnancy rates in a population and actually to raise rates of sexually transmitted diseases. 

This is thought to be due to the phenomenon of ‘risk compensation’ – people taking more risks because they believe there is a safety net.

But regardless of the reasons for a given doctor’s objection to prescribing ‘emergency contraception’, the fact that a patient can legally access it does not mean that every doctor thereby has a legal or ethical duty to supply it.

Doctors should not be forced to provide treatments or interventions that they believe are unethical, ineffective or inappropriate. To force them to do so would be to undermine their professional integrity. They are not simply rubber stamps.

Instead reasonable accommodation should be made. And thankfully both the law and the GMC guidance currently allow for that. 

As the recent CMF File on the doctor's conscience concludes: 

The right of conscientious objection is not a minor or peripheral issue. It goes to the heart of medical practice as a moral activity....  The right of conscience helps to preserve the moral integrity of the individual clinician, preserves the distinctive characteristics and reputation of medicine as a profession, acts as a safeguard against coercive state power, and provides protection from discrimination for those with minority ethical beliefs.

(Listen to my BBC London Interview with Vanessa Phelps here)


  1. If they have moral objections to something as basic as emergency contraception (which prevents pregnancy), then they should never have become doctors in the first place.

    Policies like this will inevitably lead to unwanted pregnancies (and thus higher abortion rates) if women cannot find a chemist willing to prescribe emergency contraception in time.

    1. There is no evidence that the introduction of emergency contraception has reduced levels of unplanned pregnancy or abortion.

      Doctors have good reasons (outlined above) for wanting not to participate in this 'treatment'.

      True professionals exercise conscience - they are not mere servants of the state and should not bow to coercive state power.

    2. Do you have any studies that show the inefficacy of emergency contraception?

      What are those reasons? The edicts of an anachronistic, woman-loathing religion?

      I agree that doctors aren't servants of the state. Even so, their first duty should be to the well-being of their patients.

    3. The studies are linked in the article above.

    4. I can't access the article without registering. In any case, it is also irrelevant. Women should not be denied access to Plan B contraception by arrogant moralists.

    5. Nobody's being denied access to anything. The notice gives very clear instructions on where women can go to access Plan B if a doctor who is willing to prescribe is not available.

    6. Rosy, are you unaware that Plan B medication must be taken swiftly after intercourse? Making access more onerous will lead to more unwanted pregnancies. It also violates a woman's right to prevent pregnancies they do not wish to endure.

    7. Yes, I do understand that. But I also understand that every GP surgery has a chemists very close by. I hardly think 2 minutes to nip across the road is going to make a great deal of difference.

      The problem is that sexual availability has become so expected in our culture and, of course, women bare the brunt of it because it's their bodies that they have to be constantly kept under control with various chemical products. I do sympathise with a woman whose boyfriend didn't put the condom on properly or who wouldn't wait a few weeks for the pills to start working. And when you're in a bit of a panic it probably feels rather like people are blaming you.

      Still, I repeat what I said before. There are some people in society for whom playing Russian roulette with the creation of human life just isn't acceptable. They have to be able to opt out.

    8. Also worth pointing out that this is a GP surgery, not a family planning clinic. It's for sick people who want to get well, not pregnant people who want to get unpregnant. If it was a family planning clinic refusing to hand out the morning-after pill I would be on your side.

    9. So women should be punished for having sex? That seems to be what you're implying. I bet you would be quite livid if a restaurant asked you to leave because they didn't like your clothes, even if you were not violating their dress code.

      If it was really about reducing abortion rates and unwanted pregnancies, pro-lifers would be funneling their budgets to comprehensive sex education, not disingenuous, lie-ridden abstinence-only education.

    10. Where did I say that women should be punished for having sex? Please quote me before making groundless assertions. What's the point in having a conversation with someone who's already made up their mind what other people think and what they're motivated by?

      I've said already that I personally don't have a moral problem with the morning-after pill, and that I do feel for women who've had an accident, or been pressured into sex by their boyfriend, or just got drunk and done something a bit unwise. (If you've been raped, you should go straight to a rape-crisis centre where one of the things they'll do is give you the morning-after pill).

      What I'm trying to explain is the importance of the principle of a professional doctor being able to carry on in general practice (not a specialist family planning clinic) without violating his/her conscience.

      Also, this is an interesting philosophical point - are you saying that pregnancy is a punishment?

      I'm also interested in this 'disingenuous, lie-ridden abstinence-only education'. My own school sex-education wasn't entirely comprehensive. They didn't teach me about contraception failure rates. They didn't teach me about the morning-after pill. And they didn't teach me about abortion procedures. All they taught me how to do is put a condom on - which isn't exactly rocket science!

    11. It was implied when you said the following:

      "There are some people in society for whom playing Russian roulette with the creation of human life just isn't acceptable. They have to be able to opt out."

      "The problem is that sexual availability has become so expected in our culture and, of course, women bare the brunt of it because it's their bodies that they have to be constantly kept under control with various chemical products."

      And let's not forget that Plan B contraception prevents pregnancy by preventing implantation. It is NOT an abortifacient.

    12. OK. In the first quote I was trying to explain how contraception might appear to a Catholic - and all contraception can fail.

      The second quote is simply a statement of fact - sex leads to pregnancy and if sex is going to be available without the pregnancy then (generally) it's women's reproductive systems need to be kept under control. (Men can, of course, get the snip, but it mainly falls on women).

      Nobody said anything about punishment. Pregnancy is the natural result of sex unless you manage to circumvent it in some way. People disagree over which of those ways are morally acceptable.

    13. Why should women bear most of the responsibility? Most doctors will not give young women oophorectomies because they're irreversible.

      If you don't think pregnancy qualifies as a punishment, I would highly recommend that you do some research into the unpleasant consequences endured by women even in the smoothest pregnancies with the aid of modern technology.

    14. I don't really understand what you mean. Unless I'm mistaken about your gender, I think I have a bit more experience of childbirth than you! And those various technologies used to prevent pregnancy can be uncomfortable and have various side effects. So, sex is a bit of a pain for women either way. Guys are more prepared to wear condoms than in the past, but it's not wise to totally rely on those.

      Why should women bear most of the responsibility? Good question. It's not very fair, is it? But what do you want me to do about it? Who's punishing women for having sex? God? Nature?

      Let's try looking at it this way. Sex leads to babies. Quite often people want to have sex without the baby. Different cultures have come up with various ways of dealing with this problem, including killing the baby at birth, leaving the kid out in the desert to die, killing the fetus in the womb, giving the woman various potions to induce an early abortion, giving women various potions to ensure that the fertilised egg does not implant in the womb, giving women various potions to make them infertile, and using various devices to prevent the sperm meeting with the egg in the first place.

      Where do you draw the line? Is banning infanticide punishing women for having sex? Was the British woman who was sent to prison recently for giving herself a late-term abortion being punished for having sex? In some states in America, what she did would have been entirely legal.

    15. You're right; I don't have any firsthand experience of pregnancy. Even so, I am aware that pregnancies are far from pleasant, as this list shows:

      Sex can lead to pregnancy, yes. Does that entail that consenting to sex is the same as consenting to pregnancy? I would argue against this viewpoint.

      When abortions occur, the fetus/embryo/blastocyst is incapable of survival outside the woman. If you want abortions to be eradicated (or close to it), I would suggest that you fund artificial womb research, enabling pregnancies to be brought to term without placing the woman at risk.

    16. This isn't about what I want. The question we're discussing here is whether a doctor should be able to opt out of giving drugs or being involved in procedures that he or she is not morally comfortable with.

    17. In the case of contraceptives, I would argue against the doctor's "right" to deny their patient standard medication and care based on their personal conscience.

    18. @ Winston

      "If they have moral objections to ... emergency contraception ... they should never have become doctors in the first place."

      1) Emergency contraception probably did not exist when they became doctors.

      2) We have always accepted into the medical profession those who won't prescribe contraception. Having to wait a few hours or days for a different doctor to prescribe non-emergency contraception is no hardship to any patient. I agree that emergency contraception is different. However, GPs still have the right not to provide certain services that they would be allowed to provide, under their contracts with the NHS. All doctors the duty to make clinical judgments rather than simply give patients prescriptions for whatever drugs the patients demand. And everybody has the right of conscientious objection to engaging in ethically dubious behaviours.

      3) I have my doubts, having read

      but, if Peter and the following people

      are right in asserting that the evidence is inconclusive that Levonelle does not prevent implantation, then it would be perfectly understandable if any doctor, of any faith or no faith at all, was able to take a once-and-for-all clinical decision that prescribing Levonelle was *never* going to be in the best interests of patients, in his opinion.

      By the way, many of the comments on the original story in The Independent really are very bigoted against Christians, and most of them are based upon a hypothetical scenario, rather than any facts about the particular general practice that is being pilloried.

      The story is at

      Some people are so eager to bash Christians, that they simply don't bother to read what happened. They make up their own facts, to suit the comments they want to make. It'd be funny if it wasn't tragic.

    19. There's also an assumption that this in the best interests of women, because the scenario in everybody's mind is contraception failure. This isn't necessarily true. Men haven't been unknown to say to women 'let's forget about the condom, you can take plan B tomorrow'. This especially puts young women at risk who are less likely to be on the pill than college-aged women. There just isn't an easy solution to these things.

  2. Personally, I don't have a problem with the morning after pill. It's a bit of a grey area. But the point is that people don't seem to understand what conscientious objection is anymore. The whole point in conscientious objection is that the majority of people disagree with you that something is morally wrong, but, because they respect your conscience, they respect your decision. They don't bully you into going along with them by threatening to fire you, or manipulate you into caving in by claiming that you're being mean to them.

  3. I'll put this more simply: If everybody agrees with you it's not a conscientious objection!

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