Primary Care Physicians Face Ethical Conflicts With Religious Hospitals, Study Finds

Resultant Treatment Delays May Harm Patients

May 11, 2010 04:10 pm Barbara Bein

About one in five primary care physicians who have practiced in religiously affiliated hospitals have experienced conflicts deriving from those institutions' religiously based patient care policies, according to a recent study conducted by researchers at the University of Chicago.

If a patient needs a medical intervention that is prohibited by such a hospital, most physicians surveyed for the study said they would refer the patient to another institution. Physicians practicing in medically underserved communities, however, could find making such referrals difficult because these areas typically offer fewer health care facility options, say the study's authors.

The study(, "Religious Hospitals and Primary Care Physicians: Conflicts Over Policies for Patient Care," was published online in April in the Journal of General Internal Medicine.

AAFP member and study author Debra Stulberg, M.D., instructor of family medicine and of obstetrics and gynecology at the University of Chicago, told AAFP News Now that this initial study was intended to present a "10,000-foot-high view" of whether ethical conflicts arise between primary care physicians and religiously affiliated hospitals and, if so, what impact such conflicts have on patient care.

The study revealed that not only did such conflicts arise, they most commonly involved hospital policies governing reproductive health care -- for example, emergency contraception -- and end-of-life care, such as terminal sedation.

"These are issues that people on all sides of every debate have strong feelings about, but how does this play out in practice?" Stulberg asked.

According to the study, a stratified random sample of 1,000 family physicians, general internists and general practitioners was drawn from the AMA Physician Masterfile using a special technique created to ensure that diverse religious perspectives were captured and adequately represented.

Participating physicians received a questionnaire that asked

  • whether they had worked in a religiously affiliated hospital or practice,
  • whether they had experienced conflict with the institution or practice regarding religiously based patient care policies, and
  • how they thought physicians should respond to such conflicts.

Of 446 physicians who responded to the survey, 43 percent reported having worked in a religiously affiliated institution. Of those, 19 percent had experienced conflict due to their institutions' religiously based policies. Younger physicians -- that is, those ages 26-29 -- were more likely than older physicians to report conflicts, as were physicians who reported never attending religious services.

In fact, physicians with no religious affiliation were more likely to think that "doctors should disregard religiously based policies that conflict with clinical judgment," according to the study.

The physicians were specifically asked, "What should a physician do if he/she believes that a patient needs a medical intervention, and the hospital in which the physician works prohibits that intervention because of its religious affiliation?"

Physicians were given four response choices:

  • provide the intervention openly, even if doing so risks the physician's job or hospital privileges;
  • provide the intervention discreetly to avoid these risks;
  • encourage the patient to seek the intervention at another hospital; and
  • recommend another, permitted treatment option.

By far, most physicians (86 percent) said that when such conflicts arise, doctors should encourage patients to seek the recommended intervention at a hospital where the intervention is not prohibited, the study found.

Only 10 percent of respondents said they would recommend another, permitted treatment option, and just 4 percent endorsed providing the prohibited intervention, either openly or discreetly, in violation of hospital policy.

Stulberg said she was not surprised by how most respondents answered, noting that the finding indicated that physicians "don't want to rock the boat" and risk losing their hospital privileges. But she added that patients may not benefit from going to another hospital in instances involving "time-sensitive" treatments, such as emergency contraception or certain procedures for an ectopic pregnancy.

"Emergency contraception works better the sooner it's given," Stulberg explained. "If someone comes into an emergency room and the hospital can't give it out, when the patient goes (to another hospital) an hour or two away, then it's less likely to work."

"Whether these delays are seen as harmful to the patient depends on one's beliefs about the intervention itself," the study said.

Stulberg also pointed out an additional issue: whether hospitals to which patients may be referred for treatment would accept the patients' health insurance.

Unfortunately, she said, such conflicts are likely to become more frequent as more religiously affiliated hospitals merge with, or take over, nonreligiously affiliated or secular hospitals.

The study's authors suggested that hospital administrators involve physicians in the policy-making process more fully or communicate policies more clearly to reduce such conflicts and their impact on patient care. Physicians, in turn, should inform patients about religiously based institutional policies if an admission is not urgent and other hospital choices are available.