Unconscionable Practice
Let’s cure a pound of patriarchy, shall we?
You may or may not be aware of an archaic set of federal regulations called “The Church Amendments.” Yes, you read that correctly. In short, these federal regulations protect health care providers from punishment should they refuse to participate in health care that goes against their religious or moral practices. They were established just after, and in direct response to, the Roe v Wade decision in 1973. The pharmacists who refuse to fill birth control pill prescriptions are protected by these laws, for example. When abortion became federally legal across the country, there was a bit of a panic by the pearl clutchers in that they didn’t want to “be forced” to perform abortions. So Idahoan Democratic Senator Frank Church, because of course that was his name, put forward the idea that no one could be forced to perform abortions or sterilizations if they were religiously or morally opposed to them, specifically in federally funded institutions. These folks were protected from discrimination should they refuse to provide this care: they could not be fired or denied hospital privileges, for example. As many of you know, the other side of that coin was, and still is, non-existent: it has been perfectly acceptable (if not encouraged) to fire, deny hospital privileges to, or otherwise punish health care providers who provide abortion care. Ask me how I know. Keep in mind this is all occurring during a time when the reproductive coercion of forced sterilization was common practice (see: the “Mississippi appendectomy” [1-18]) on people deemed “appropriate” in the most racist, classist and eugenicist terms. The hypocrisy and the cruelty, as they say, was the point. Since then the Church Amendments have evolved to have broader scope and wider interpretation (shocking, right?) and cover non-person entities such as insurance companies, states, and training programs.
All reproductive coercion is wrong, I hope we can all agree on that. From forced sterilization to forced birth, from forced abortion to forced pregnancy, and everything in between are all aspects of reproductive coercion. Withholding care is passive coercion just as being a barrier to accessing care is proactive coercion. None are ethical or moral on any secular or nonsecular standing. I have seen providers use their own religious beliefs to refuse placing an IUD for someone, or providing contraception generally, resulting in patients being subjected to forced pregnancy. Guess what? Their patients become my patients seeking abortion care. I am but one health care provider and I have countless stories of this happening. Yes, I said “forced pregnancy” and I meant it. If you have options, and remove all options but one, what are you left with? Certainly not “a choice.” You are forced down one path because all others were blocked, removed, barricaded, etc.1 But let’s break it down from the provider’s side: if my religion is against contraception, and therefore I am against contraception, then I do not use contraception. It is an entirely different thing to impose my religion on someone else. My right to not use contraception is protected by the First Amendment, but no where is it my right to subject others to my religious beliefs. Imagine a health care provider who said to a patient, “I’m not treating your chlamydia because you had sex outside of marriage and you shouldn’t have because it is against my religion.” It’s no different than saying, “I’m not placing an IUD in you because contraception is against my religion.” The Church Amendments, however, protect me should I decide to impose my religious beliefs on others from my position of power as a physician and deny needed health care to my patients. And let’s be clear: health care providers not trained in abortion care were never going to be forced to provide abortion care. I don’t need a federal statute to protect me from being forced to perform a heart transplant, for example. So, once again, the United States is showing how good it is at legalizing reproductive coercion (Church Amendments, Hyde Amendment, Dobbs decision, etc) and promoting its eugenics priorities.
So why talk about this now? For one thing, it’s been a thorn in my side, intellectually speaking, since the moment I learned of its existence. Also, Representative Pfluger [R-TX] introduced into Congress the Conscience Protection Act, which will further damage access to life-saving, evidence-based health care across the nation. At present it remains in the House Energy and Commerce Committee. This extension will allow for individuals and institutions to take legal action against violations instead of simply being protected against discriminatory actions. “Don’t make me do an abortion or I will sue you!” is the idea. This is creating a solution where there is no problem and will effectively further reduce already dwindling access to reproductive health care. I just need folks to understand the harmful nonsense that is this legislation.
Let’s discuss the underlying principle being used to fortify these “conscience” regulations. (The reason for the scare quotes will be apparent shortly). This principle is known as “conscientious objection” (CO) and has been around for centuries. Basically it’s the idea that a soldier can refuse orders to engage in military practices that conflict with their personal, religious or moral beliefs or practices. Broadly, this is “pacifism” and is generally accepted as a religious or personal moral code of ethics. Early invocations of CO can be traced back to the Roman Empire where Christians refused military service due to having higher loyalty to god over the emperor. The key principle behind CO is the directionality, and this is where it breaks down into nonsense as it is applied in healthcare: it is a bottom › up directionality, NOT top › down. This is to say a soldier can refuse an order from a commanding officer, but the commanding officer cannot refuse to order the soldier. The commanding officer can refuse an order from a superior officer, but… you get the idea. Basically the directionality of power is what defines CO: the one with less power refusing against the one with more power. In healthcare, the directionality is always that the health care provider is in the position of power over the patient seeking health care services. There is no other way this directionality exists. Earth’s gravity pulls toward the center of the planet, not away and toward the sky. So just as an army general cannot invoke CO when ordering a soldier to charge a hill, a physician cannot invoke CO when providing needed health care to a patient. The physician has the power, while the patient (for the purpose of this discussion) is powerless. Even the American Medical Association deems so-called CO as only a “limited accommodation” and must be met with very specific criteria, the most important of which prioritize patient autonomy, patient access to care, and beneficence over a physician’s CO. [19] Here’s the rub: if part of your job is against your moral or ethical beliefs, and specifically regarding a health care profession which directly impacts people’s lives and well-being, perhaps you should have a job that does not involve conflict with your moral or ethical beliefs. Be anything else, in other words, if you can’t do your job, especially when other people can be harmed by you not doing your job. Remember: the underlying premise is that a healthcare worker is trained in providing such care. For example, I am not trained in heart transplants so if my patient needs one, I cannot perform one but will refer them to the appropriate provider. CO does not enter the equation. There are providers who would refuse to provide abortion care, but they are also not trained to provide it either, so it is a moot point. However, to use gynecologists as an example, one should not refuse to prescribe contraception due to personal religious beliefs. You yourself may not use it due to your own personal beliefs for what is moral or immoral for yourself, but do not impose those beliefs on your patient. Your patient is not subject to your belief system. This is where that pesky patient autonomy comes in as a core medical ethic that must be prioritized, especially over the personal feelings of the health care provider. It is not to say that providers cannot or do not have feelings, but it IS to say that those feelings must not be prioritized above the patient’s autonomy. Academic scholars (such as Dr. Christian Fiala) have done a much better job describing this dilemma and I strongly encourage reading their works for a deeper discussion and perspective. [20-24] The Church Amendments were a direct response to the Roe v. Wade decision. They are archaic and they violate medical ethics.
You can imagine the importance of upholding the principle medical ethics: justice, beneficence, nonmaleficence, and autonomy. Allow me to dive into a story from my residency days. (This is a story I mentioned briefly as a footnote in a previous post). I was a third- or fourth-year resident, which means I was not brand new, but not ready to go out on my own quite yet. There was a patient in labor whose fetal monitor was showing signs of fetal distress. The patient was progressing in labor, meaning she was moving along and toward vaginal delivery, but the concerning aspects of the fetal monitor were also progressing. We opened the discussion with her, of course, that we were concerned about fetal well-being and, while we have various non-invasive interventions we can use to try to improve things, she may need a cesarean delivery to save her baby’s2 life. We would do all we could to prevent that, but the idea was to discuss the plan ahead of time instead of when there’s imminent danger and “no time for discussion.” She was very clear that she did not want a cesarean delivery. “Even if it means your baby will die without it?” “Even if it means my baby will die without it.” She explained that whatever happened to the baby “was god’s will” and that she refused a cesarean delivery. She declared she would have a vaginal delivery, even if that meant she delivered a stillborn. Did I have feelings? Oh, yes, I had feelings. I had many feelings, not the least of which included the frustration of being able to possibly save her baby and being told I am not allowed. I had feelings of sadness and worry, I had personal beliefs that this patient was making the wrong decision and that decision went against every fiber of my moral being and ethical code. I am certain I was angry with her god. I’m sorry to say, friends, that this story ends with her delivering a stillborn. My heart broke for her and her family, but I could live with that outcome because I respected her autonomy. Imagine if I had put my personal feelings and beliefs above her autonomy…and had performed major abdominal surgery on her without her consent and, moreover, against her will. That, to say the very least, is assault and battery, which is nothing to say of the violence that I would have perpetrated against this woman had we ignored her authority. What if she had life-long morbidity after the surgery? What if she had died from complications after the surgery? What if the newborn had some lifelong illness or debilitation and was to suffer? What if her newborn only survived a few days and before it died she and her family were forced to watch as it suffered and breathed its last breath? What an unforgiveable trauma to inflict, even without any complications: a delivery against someone’s will. The moral of this story is no one in health care can predict the future or outcomes of patient decisions. There is just no way to know what the “best” decision is for any one patient, which is why there are codes of ethics involving informed consent and respecting patient autonomy. I disagreed with that patient’s decision, but it wasn’t my body or my pregnancy or my family or my life that was involved. It was hers: her body, her pregnancy, her family, her life.
I cannot tell that story without declaring that fetal personhood would have required me, by law, to perform that cesarean delivery against the patient’s will and autonomy. Yes, fetal personhood would erase assault and battery against pregnant people in favor of prioritizing the fetus over the pregnant person. This is what the “fetuses are people” movement wants: protect the fetus, pregnant person be damned. Fetuses are not people, cannot be people, and must never be legally declared as people. We already know the harms that come with fetal personhood [25-40].
One way to violate patient autonomy is to invoke CO and refuse necessary and evidence-based care to a patient. It is psychologically traumatic to the patient in addition to the other harms inflicted by the denial of care. Why are you a pharmacist if you won’t dispense the medications a practitioner prescribed? Why are you a gynecologist if you won’t provide what your patient needs to avoid pregnancy? Religious freedom means you may not be punished for practicing your religion. Religious freedom does not mean you may punish others for not practicing your religion. Is contraception against your religion? Fine, don’t use it. It doesn’t mean you are not allowed to prescribe it or fill the prescription for someone else. If you feel it does, then do ANY OF THE OTHER PROFESSIONS AVAILABLE IN THE WORLD. If you can’t reconcile the difference between practicing religion on yourself versus practicing it on others, I think you most certainly should not be working in health care. I said what I said. (Please note that I have worked with physicians who refused care to patients based on much less than CO, which is another discussion entirely.)
The Church Amendments, the Hyde Amendment, the Dobbs decision, the Conscience Protection Act and all the reproductive coercion our country has enshrined in legislation need to be abolished. They are unconscionable. They further delay access to abortion care, prenatal care, ALL the reproductive health care, for one thing. The last time I checked, people don’t get less pregnant as time goes by, and 100% of pregnancies alter human physiology putting health and life at risk. In the name of reproductive justice, I declare Conscientious Objection to the refusal of providing health care. I object to NOT providing the health care patients need – it is against my moral code and against medical ethics in general. Where is the legislation protecting the ability to do that?
“Reproductive justice is the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” -Loretta Ross
Citations:
1. Roberts, D. (1997). Killing the Black body: Race, reproduction, and the meaning of liberty. Pantheon Books.
2. Ross, L., Solinger, R., & other contributors. (2004). Undivided rights: Women of color organize for reproductive justice. South End Press.
3. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on Black Americans from colonial times to the present. Doubleday.
4. Ross, L., & Solinger, R. (2017). Reproductive justice: An introduction. University of California Press.
5. Bleiweis, R. (2020, October 28). Mississippi appendectomies: Reliving our pro-eugenics past. Ms. Magazine. Ms. Magazine article
6. Independent Lens. (n.d.). Unwanted sterilization and eugenics programs in the United States. PBS. PBS Independent Lens article
7. Luterman, S. (2022, February 4). 31 states have laws that allow forced sterilizations, new report shows. The 19th. The 19th article
8. Chen, A. (2021, February 8). How organizers are fighting an American legacy of forced sterilization. YES! Magazine. YES! Magazine article
9. Pender, G. (2020, September 16). ICE detainees’ alleged hysterectomies recall a long history of forced sterilizations. Mississippi Free Press. Mississippi Free Press article
10. Braveman, P., et al. (2022). Abortion access as a racial justice issue. New England Journal of Medicine, 387(16), 1495–1497. https://doi.org/10.1056/NEJMp2209737
11. Ainsworth, A. J., & Farley, A. N. (2023). Suggestions for political reparations for reproductive injustice. Frontiers in Reproductive Health, 5. https://doi.org/10.3389/frph.2023.980828
12. Texas Undergraduate Law Review. (2026). Three generations of imbeciles: Past and present coercive sterilization in the U.S. Texas Undergraduate Law Review. Texas Undergraduate Law Review article
13. Schoen, J. (2019, July 24). The politics of reproductive rights legislation in the modern South. Nursing Clio. Nursing Clio article
14. SisterSong Women of Color Reproductive Justice Collective
15. In Our Own Voice: National Black Women’s Reproductive Justice Agenda
16. National Women’s Law Center
17. No Más Bebés. (2015). [Documentary]. ITVS; Independent Lens.
18. American Experience. (n.d.). Fannie Lou Hamer. PBS. PBS American Experience: Fannie Lou Hamer
19. AMA Code of Medical Ethics, Opinion 1.1.7
20. Fiala, C., et al. (2016). Yes we can! Successful examples of disallowing “conscientious objection” in reproductive health care. The European Journal of Contraception & Reproductive Health Care, 21(3), 201–206.
PMID: 26838273
21. Fiala, C., & Arthur, J. H. (2017). Refusal to treat patients does not work in any country—even if misleadingly labeled “conscientious objection”. Health and Human Rights Journal, 19(2), 299–302.
PMID: 29302184
22. Arthur, J. H., & Fiala, C. (2018). The FSRH guideline on conscientious objection disrespects patient rights and endangers their health. BMJ Sexual & Reproductive Health, 44(2), 145.
PMID: 29921641
23. Fiala, C. (2025). How to discourage belief-based denial of abortion care. The European Journal of Contraception & Reproductive Health Care.
PMID: 40177948
24. Fiala, C., Arthur, J. H., & Martzke, A. (2025). Origin of “conscientious objection” in health care: How care denials became enshrined into law because of abortion. Journal of Law, Medicine & Ethics.
PMID: 40340961
25. Associated Press. (2025, September 30). More women are charged with pregnancy-related crimes since Roe’s end. AP News.
26. Cineas, F. (2024, August 22). The rise of pregnancy criminalization post-Dobbs. TIME.
27. Luthra, S. (2025, June 30). Texas capital murder case attempts to severely punish abortion pill use. The Texas Tribune.
28. McCann, A., & Putterman, S. (2023, July 25). These states are using fetal personhood to put women behind bars. The Marshall Project.
29. PBS NewsHour. (2024, October 1). After overturn of Roe, more women face prosecution for what they do while pregnant. PBS.
30. Sherman, C. (2025, April 4). Georgia woman’s miscarriage prosecution highlights rise in pregnancy criminalization. The Washington Post.
31. Sherwood, H. (2025, September 30). Hundreds of US women charged with pregnancy-related crimes since fall of Roe. The Guardian.
32. American College of Obstetricians and Gynecologists. (2020). Opposition to criminalization of individuals during pregnancy and the postpartum period. ACOG.
33. CUNY School of Law Human Rights and Gender Justice Clinic. (2023). U.S. criminalization of abortion and pregnancy outcomes. City University of New York School of Law. CUNY Report.
34. Legal Voice. (2024). Legal fetal personhood timeline in the U.S.
35. Paltrow LM, Flavin J. Arrests of and forced interventions on pregnant women in the United States, 1973-2005: implications for women's legal status and public health. J Health Polit Policy Law. 2013 Apr;38(2):299-343. doi: 10.1215/03616878-1966324. Epub 2013 Jan 15. PMID: 23262772.
36. Pedone, J. (2017). Model legislation for fetal homicide crimes. Journal of Law and Social Policy, 26, 43–74.
37. Pregnancy Justice. (2024). Pregnancy as a crime: A preliminary report on the first year after Dobbs.
38. Pregnancy Justice. (2025). Pregnancy as a crime: An interim update on the first two years after Dobbs.
39. Pregnancy Justice. (2024). The rise of pregnancy criminalization: A pregnancy justice report.
40. Ziegler, M. (2025). Fetal personhood and reproductive criminalization. New England Journal of Medicine, 392(4), 301–304.
1You may have heard the argument “having sex is a choice.” Well, maybe? We must acknowledge that sexual assault still occurs. Human beings have not evolved far enough to have ceased doing that. Also, sexuality is part of our genetic make-up. So when someone says, “Just don’t have sex” as a solution to undesired fertility, what I hear is “Just don’t sleep [if you don’t want nightmares].” “Don’t have sex” is not even a realistic suggestion for anyone who is not asexual. For those who are pregnancy capable and whose sexuality includes sex that involves sperm exposure, health care to prevent undesired fertility is required (contraception, abortion, evidence-based fertility awareness, etc).
2This is language the patient used. She referred to her pregnancy/fetus as a “baby.” It is important to respect the language and terms patients use.
