Is it Ethical to Refuse to Treat a Patient due to Sexual Identity?

[Lynda Lampert, RN]

Patients come in all sorts of flavors. You have your frequent flyers, your noncompliants, your criminals, and your sweet little senior citizens. All patients are different, and this is part of the joy of nursing. Everyone has their own story, and we get to listen to them, help them, and see them flourish. While not everyone agrees with it, patients come in all kinds of sexual orientations, too. You can have those who are gay, bisexual, transexual, or transvestites. Just a normal day on the job for a nurse, right?

Sexual identity is a hot button issue, and it is becoming hotter. The internet almost blew up a few weeks ago about a Michigan law that purported to allow EMS personnel to deny treatment to patients who identified with a particular sexual identity. Supposedly, this bill allowed medical personnel to refuse based on religious beliefs. You can't believe everything you read on the internet, folks, and there is more to this story than meets the eye. It still brings up the ethical question: can medical workers refuse to treat those who violate a strongly held religious belief?

What the Michigan Bill Says

The bill currently under consideration in Michigan is called the Religious Freedom and Restoration Act, or RFRA. It is currently in the Michigan house, where it was proposed, and still has to work through the system and be signed by the government before it is law. Therefore, the RFRA is not a law in Michigan, despite what the internet says. It is a long, long way from that, and it could change drastically as the politicians get their hands on it. No need to worry, really. It's just an idea at this point.

Another crucial bit to understand is that the bill does not specifically give medical personnel the right to refuse treatment to gay people. The bill doesn't mention medicine or homosexuals at all. Instead, the bill suggests that a person who is by law required to act can choose not to act due to a strongly held religious belief. This means that it could be used as a defense in court if the one who should act is sued by the one not acted upon. Mostly, this would entail civil cases, but this isn't where the story ends.

Possible Scenarios Arising from the Bill

As most lawyers do, far more has been read into this bill than originally intended. Opponents of the bill have suggested that this law could be applied to medical personnel, from doctors to nurses to EMTs. In fact, it could affect any person required by law to act, and they would be in their rights to refuse. Please note, this is not what the bill says, but it is merely a possibility that could be read into the law to protect a medical professional who didn't act when they were required to.

It also brings up the idea of religious freedom. If you know that someone is gay and you disagree with that, do you have to act? The proposed law technically says no. When you hold a sincere and strong religious belief about something, the state cannot force you to act against those beliefs -- even if it means that someone else suffers because of it. This is a bit about the separation of church and state in addition to medicine. How far do religious beliefs go? Can you refuse someone anything because they don't agree with your religious point of view? For instance, should you be forced to rent your property to someone who is gay? According to this law, you wouldn't have to, and that would get you out of a discrimination suit.

Should Healthcare Workers have the Right to Refuse Treatment?

Despite the fact that this bill is far from a law and despite the fact that it doesn't directly affect medical workers, it does bring up a disturbing question: do nurses have the right to refuse to treat patients who are gay? Look at it this way: Do we have the right to refuse treatment of someone with HIV or Ebola? Do we have the right to refuse treatment of a patient whose religion is different than ours? Do we have the right to refuse treatment to those who have a violent criminal past? I have taken care of child molesters, rapists, and murders. I certainly don't agree with their actions, but I took care of them to the best of my ability.

Why is it different for someone of a different sexual orientation? It all boils down to the patient. Here is someone sick in front of you. Does it matter how they have sex? Does it matter what they believe? Do you have the right to play God and decide who lives and who dies? No matter who our patients are, I believe that we have the legal and ethical responsibility to care for them to their last breath. We didn't come into nursing to pick and choose those that we will care for, and politics does not belong at the patient's bedside. Instead, nurses should care for who they are charged with -- criminal, homosexual, black, white, Islamic, or whatever. No one should be denied care, and that includes the modern day lepers, those with a different sexual identity.

References

Michigan House Bill No. 5958; Accessed January 9, 2015

http://www.legislature.mi.gov/documents/2013-2014/billengrossed/House/pdf/2014-HEBH-5958.pdf

Snopes; Slake Michigan; Accessed January 9, 2015

snopes.com: Michigan Exempts Emergency Medical Personnel from Treating Gay People?

[dishes, BSN, RN]

@Lynda the target audience that you are writing to on AN is not the general public, it is experienced nurses who are familiar with the nursing code of ethics and justice in healthcare. The general audience may prefer to read rumours and speculation about a proposed bill, but as an experienced nurse, I prefer facts like traumaRus suggested; the history of the bill, who initiated it, who is lobbying for it, which ethical principles and human rights may be violated.

[KellyRN2013]

I do not think it is ethical at all! When you become a nurse you know that you will be taking care of patients of all races, sizes, ethnicities, and sexual preferences. God for bid that would be awful if there were a huge wreck and the EMT's came to the wreck and refused to take care of the critically injured people just because of THEIR sexual preference. Who are we to judge as human beings? It is not up to our own opinions who others should love and how they should act. This is absolutely ridiculous for a state to pass a bill like this. I would only hope that they would ask people they are interviewing if they would deny care to a certain race or sexual preference. If they were to answer "yes" that they would deny care I would not hire them because we take care of ANYONE in need in the healthcare field!!!

[nurseprnRN, BSN, RN]

Just in case it wasn't clear in the article, I don't feel it would be ethical either. I think it is important to know what this bill is about and how it may affect healthcare. Unfortunately, this IS a question that will be asked in the future. It has the potential to be a problem, and medical professionals have to be ready to act against it.

I doubt that any ethical "medical professional" (by which I assume the popular press and lay public means physicians, nurses, therapists, dentists, and members of any other caregiving profession) would give this dreck a second look. We all learned better than that in school. The ethical imperatives of beneficence and nonmaleficense are settled principles for us.

What kind of fool in the MI legislature dreamed this one up? Surely it couldn't have been a real healthcare person; we all have known better since we were first-year students. You can tell 'em I said so.

Beneficence vs. Nonmaleficence

[GrumpyRN, NP]

Is this unethical? That is not the question, the OP has made it clear that the bill has been hyped. So as nurses it should not change what we do in any way and of course any suggestion of this type of discrimination is unethical.

My concern is that someone somewhere has thought it a good idea to limit the freedoms of a particular subset of your population because what they do goes against your particular 'good book'. This has the potential to be an appalling abuse of civil liberties/rights.

I would personally never assist with an abortion but I would never apply for a job at an abortion clinic and expect them to accomodate me either. I have worked in Christian based facilities whenever possible because it allows me to practice without conflicting with my faith. I don't tell my patients or supervisors what to believe but they don't tell me what to believe either. It's about what you value most and how far you are willing to go to uphold those values.

So, how far ARE you willing to go to uphold those values?

[kbrn2002, ADN, RN]

Of course this is absolutely ludicrous. No health care professional would deny care based on a patients sexual identity, or any other lifestyle choice. What I find fascinating is that a bill like this would even get this far. I can't imagine what else the kind of politician that would author a bill like this supports, nor those politicians that endorsed the bill. Sounds like political suicide to me.

[Gooselady, BSN, RN]

GrumpyRN said:

My concern is that someone somewhere has thought it a good idea to limit the freedoms of a particular subset of your population because what they do goes against your particular 'good book'. This has the potential to be an appalling abuse of civil liberties/rights.

Thank you. You can't spit on a cupcake and call it frosting. Hobby Lobby ain't gonna be remembered fondly for their 'win'.

The younger generations are MARKEDLY in favor of LGBTI freedoms of lifestyle, parenting, professionalism and political support. This in spite of the temporary 'success' of the political religious right and their quiverfuls of future voters. It is crass to say but it looks like the folks SO impossibly entitled to even come up with such a bill are simply going to die off.

[Here.I.Stand, BSN, RN]

Of course it's not ethical. The Bible doesn't forbid the physical care of anyone anyway, so there are no religious tenets being violated--at least no Judeo-Christian tenets. To base a refusal of care on that has no justification. What people do in their bedrooms really doesn't have anything to do with the nursing care that they need.

I have cared for murderers. That has caused some unpleasant sensations in my throat...but I still do my job.

[nursel56]

You know, it is refreshing to hear so many nurses and healthcare providers agreeing with me. I think the bill is BS, too. I also think that the hoopla surrounding it is hysteria. It's a hypothetical and a legal issue. When writing this, I felt more like I was writing an investigative law article than a nursing one.

I think that most of us are smart enough to avoid the abortion issue, if it bothers us. Would you take care of a woman who came into your ER after a botched abortion? Would you have a hard time with that?

No, and I've really been trying to figure out (as a non-lawyer) how this law foresees an issue with playing God and choosing who lives and who dies. On the face of it, it is just as many people have said, an obvious civil rights violation because an individual is violating an obvious "right to life" protection of an already born, unquestionably alive person.

In the case of treating a woman with a botched abortion, my understanding is that people of some faiths are allowed to opt out of assisting in the procedure itself. I was in the past employed at a facility that performed abortions, and due to the make-up of the staff, I ended up being the only person who assisted with them. I'd rather not have to be honest but I weighed it out and decided the woman might have a higher chance of complications if the provider did the procedure alone.

In the ED, it would seem that EMTALA would trump a nurse's objection to treating the bleeding, infection you would encounter in a botched abortion.

I did look up the details of this law and was surprised to find out that anyone would question the Constitutionality of the healthcare provider scenario, but most of those articles don't mention it in that context. The law states that a neutral law can apply in cases of religious freedom, which I understood to mean the law doesn't have to state specifically "you may not pray, you may not wear religious symbols,etc"

I don't think it's actually a law that any healthcare provider is mandated to care for any patient no matter what, so the only other thing I could think of that would apply a mandate are civil rights laws. So my question would be are things like the Federal Housing Act, and other non-discrimination laws based on equal protection "neutral" laws?

Thanks for writing the article! I love it when somebody prompts me to get the rusty ol' mental gears going. :-)

[Brandidrn]

Madness I speak for me and me only when I say I have never refused to treat or care or give them my 110% and the thought that I would even ask their sexual orientation or religious beliefs not related to their care or whatever unnecessary is crazy madness. I want to help each person and make a difference even when they accuse me of doing less than my best cause of their language spoken or type of insurance. I need no thanks or good job from anyone cause I know so the thought of not acting to do what is best for each patient and their family to ensure the best outcomes possible and advocating for them when they can't to respect their wishes regardless of what I believe is ludicrous!

[Kooky Korky, BSN, RN]

Who is actually required to act? I guess that would include EMT's, paramedics, ER workers, workers who take on the nurse-patient relationship and accept their assignments by arriving at work, getting report, and initiating their shift - somewhere along the timeline, we have accepted our assignment and are not allowed to abandon it. If we become ill or receive terrible news that makes us distraught (like about a member of our family or something as awful as that) and unable to be competent for the time being, we might be excused from our duties.

Should those who are required to act be allowed to not act if they find the pt's sexuality, religion, color, shape, or hairdo unacceptable? No.

However, it might be best for all concerned - staff, patient, pt's family/SO's - to have care done by someone who has no issue with the patient.

Should someone be forced to provide abortions or recover voluntarily aborted women? No, unless the mother's life is at stake. Then we should do what has to be done and go to our conscience or God about it later. No, I am not in favor of abortion on demand. Yes, there are times when I think it is the best choice of some very difficult choices.

I guess this current question is like the one pharmacists face when a woman wants an abortifacient pill that the pharmacist objects to based on religious views.

This is not an easy world. But let's always do our best to take good care of each other to the best of our ability. And to take good care of ourselves, too.

[anon456, BSN, RN]

ANA Code of Ethics, provision #1

The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

1.2 Relationships to patients

The need for health care is universal, transcending all individual differences. The nurse establishes relationships and delivers nursing services with respect for human needs and values, and without prejudice. An individual's lifestyle, value system and religious beliefs should be considered in planning health care with and for each patient. Such consideration does not suggest that the nurse necessarily agrees with or condones certain individual choices, but that the nurse respects the patient as a person.

Nurses should hold themselves to a higher standard than these ridiculous laws. Other medical workers, too.

[riggy3, MSN, RN]

Is it ethical to refuse to treat because of difference of religious belief NO!

In my past experience working with nurses who would not care for patients who had abortions postoperatively was a big ethical question. They were not forced to participate in the procedure in the operating room because of religious belief.

At the stage in recovery room this is another surgical patient who needs care to recover. Still there were some nurses who refused to care for the lady. At this point to solve the ethical issue a decision by these nurses was to quit and work at a hospital who did not do the procedure.

Such a ludicrous piece of legislation is wasting lawmaker time. Someone with just of small bit of common sense surly should vote on that as NO discussion necessary. Next Bill