Washington, USA - In Chicago, an ambulance driver refused to transport a patient for an abortion. In California, fertility specialists rebuffed a gay woman seeking artificial insemination. In Texas, a pharmacist turned away a rape victim seeking the morning-after pill.
Around the United States, health workers and patients are clashing when providers balk at giving care that they feel violates their beliefs, sparking an intense, complex and often bitter debate over religious freedom vs. patients' rights.
Legal and political battles have followed. Patients are suing and filing complaints after being spurned. Workers are charging religious discrimination after being disciplined or fired. Congress and more than a dozen states are considering laws to compel workers to provide care -- or, conversely, to shield them from punishment.
Proponents of a "right of conscience" for health workers argue that there is nothing more American than protecting citizens from being forced to violate their moral and religious values. Patient advocates and others point to a deep tradition in medicine of healers having an ethical and professional responsibility to put patients first.
The issue is driven by the rise in religious expression and its political prominence in the United States, and by medicine's push into controversial new areas. And it is likely to intensify as doctors start using embryonic stem cells to treat disease, as more states legalize physician-assisted suicide and as other wrenching issues emerge.
"What constitutes an ethical right of conscience in medicine, and what are the limits?" asked Nancy Berlinger of the Hastings Center, a bioethics think tank. "This keeps getting harder and harder for us."
For Debra Shipley, her duties as a nurse began to conflict with her Christian faith when the county health clinic where she worked near Memphis required she dispense the morning-after pill.
"I felt like my religious liberties were being violated," said Shipley, 49, of Atoka, Tenn. "I could not live with myself if it did it. I answer to God first and foremost."
But Paige Gerson, 37, of Leawood, Kan., believes doctors and nurses should never let their personal values interfere with patient care. Her doctor refused to give her the morning-after pill, citing religious objections.
"I was incredibly angry and just scared to death," Gerson said. "I think it's absolutely wrong to impose your religious beliefs on someone else."
The debate over the right of conscience in health care is far from new. After the 1973 Roe v. Wade decision, many states passed laws protecting doctors and nurses who did not want to perform abortions. Oregon's 1994 legalization of physician-assisted suicide lets doctors and nurses decline to participate.
The clash resurfaced with antiabortion pharmacists refusing to fill prescriptions for the morning-after pill. But recent interviews with dozens of health-care workers, patients, advocates, ethicists, legal experts and religious and medical authorities make it clear that the issue is far broader. Many health-care workers are asserting a right of conscience in many settings.
"This issue is the San Andreas Fault of our culture," said Gene Rudd of the Christian Medical & Dental Associations. "How we decide this is going to have a long-lasting impact on our society."
Some anesthesiologists refuse to assist in sterilization procedures. Respiratory therapists sometimes object to removing ventilators from terminally ill patients. Gynecologists around the country may decline to prescribe birth control pills. Some doctors reject requests for Viagra from unmarried men.
The conscience debate has a flip side: Some health workers chafe at requests to take extraordinary measures for terminally ill patients or object to Catholic hospitals' bans on abortions, sterilizations and the morning-after pill.
The issue has become acute for some religious workers, especially devout Christians, for whom the concept of "conscience" plays a particularly prominent role. One development after another has challenged their values: treatments using fetal tissue; physician-assisted suicide; the RU-486 abortion pill; the morning-after pill; fertility clinics discarding thousands of excess embryos; and now a looming wave of therapies derived from embryonic stem cells.
"Medicine today is being asked to do all sorts of things that are in conflict with its fundamental healing traditions," said William B. Hurlbut of Stanford University, a member of the President's Council on Bioethics.
The controversy is part of the larger struggle over religion's place in society, mirroring in some ways the fight over teaching alternatives to evolution in schools.
"What the conscience debate, the euthanasia debate, the stem cell debate and the evolution debate all have in common is this collision between a religiously inspired view of life and state regulation," said John C. Green of the Pew Forum on Religion & Public Life, a nonprofit research center.
The issue of refusals in medicine has mostly percolated quietly. Many conflicts are settled informally. Some health-care workers avoid or transfer out of jobs that present moral quandaries. When a conflict arises, co-workers typically step in. Patients often never know it happened.
But confrontations do occur when, for example, hospitals or clinics are unable or unwilling to accommodate a worker's objections. Or an employee refuses to refer patients elsewhere, or is on duty alone or gets drafted to fill in for someone else. Problems sometimes arise after a worker undergoes a religious awakening.
In response, hospitals and other facilities, along with medical groups including the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, are crafting policies to defuse potentially explosive run-ins. Lawyers, ethicists and advocates are sparring over how to balance the conflicting rights.
"Freedom of conscience has been central to our political notions since even before the United States existed," said Loren Lomasky, a philosophy professor at the University of Virginia. "People should not be forced into doing things that they find morally odious."
Lomasky and others liken religious objections to abortion, sterilization, and euthanasia to conscientious objections to the Vietnam War and the recent refusal of anesthesiologists in California to participate in executions.
"Why is it that some people would have no compunction in forcing a doctor to participate in an abortion, but if it's painful death by lethal injection, they suddenly find religion?" asked Lynn D. Wardle of Brigham Young University's J. Reuben Clark Law School.
Some argue that health workers should not even be required to refer patients elsewhere for care they find objectionable.
"Think about slavery," said physician William Toffler of the Oregon Health and Science University in Portland. "I am a blacksmith and a slave owner asks me to repair the shackles of a slave. Should I have to say, 'I can't do it but there's a blacksmith down the road who will?' "
Others say that professional responsibility trumps personal belief.
"As soon as you become a licensed professional, you take on certain obligations to act like a professional, which means your patients come first," said R. Alta Charo, a bioethicist and lawyer at the University of Wisconsin at Madison. "You are not supposed to use your professional status as a vehicle for cultural conquest."
Religious objections can be dangerous in emergencies and when health workers refuse to refer patients or inform them about other options, especially in poor or rural areas where there are fewer options.
"It's a very disturbing trend," said Lourdes Rivera of the National Health Law Program, a nonprofit patient advocacy group.
Doctors, nurses and other health-care workers who cannot find a way to fulfill their responsibilities should chose other professions, some say.
"If your religious orientation is such that you can't discharge your professional responsibilities, then you shouldn't take on those responsibilities in the first place," said Ken Kipnis, a philosophy professor at the University of Hawaii at Manoa. "You should find other work."
Others are less sure where to draw the line.
"The bottom line is, this is a vexed question," said John A. Robertson of the University of Texas School of Law. "There's not some clear way through this thicket yet."