Proposed changes to the Title X Family Planning Program

According to the American Medical Association's (AMA) Code of Medical Ethics, “truthful and open communication between doctor and patient is essential for trust in the relationship and for respect for autonomy.”1American Medical Association Council on Ethical and Judicial Affairs Code of Medical Ethics. American Medical Association, Chicago, IL2016Google Scholar The doctor's role is to assist patients in making autonomous, informed decisions about their health care through counselling and to refer for care if the doctor cannot provide it. A new regulation proposed by the US Department of Health and Human Services would require providers in the Title X Family Planning Program to withhold information from patients and therefore violate the AMA ethics code. Title X provides reproductive health care to those who cannot afford it. Health-care providers participating in Title X serve more than 4 million people who are disproportionately low-income, young, and of colour. Since its inception, the programme has operated with the prohibition that “none of the funds appropriated under this title shall be used in programs where abortion is a method of family planning”.2Department of Health and Human Services http://www.federalregister.gov/d/2018-11673Date accessed: July 19, 2018Google Scholar Until now, clinicians who care for patients in this programme could provide ethical care despite this prohibition because they have offered comprehensive pregnancy options, counselling, and referrals. The proposed rule regulating Title X would change that through prohibiting all services that “indirectly facilitate, promote, or encourage abortion in any way”,2Department of Health and Human Services http://www.federalregister.gov/d/2018-11673Date accessed: July 19, 2018Google Scholar and will interfere directly in the relationship between patient and provider because those working in Title X-funded facilities would be prohibited from referring for abortion services, even at the direct request of patients. In the case of a pregnant patient who has made a clear decision to have an abortion, a doctor would be permitted to provide a list of comprehensive health-care providers, some (but not all) of which provide abortion in addition to prenatal care.2Department of Health and Human Services http://www.federalregister.gov/d/2018-11673Date accessed: July 19, 2018Google Scholar The doctor would be prohibited from indicating which of these facilities offer abortion services, leaving patients to obtain the information they have explicitly requested. This stipulation violates the medical ethics of referrals, which require that providers refer to professionals who have “appropriate knowledge and skills and are licensed to provide the services needed”.1American Medical Association Council on Ethical and Judicial Affairs Code of Medical Ethics. American Medical Association, Chicago, IL2016Google Scholar The potential violations of medical ethics go beyond withholding information and making unethical referrals. Delaying access to abortion care has serious health risks. Although abortion is safe overall,3National Academies of Sciences Engineering and Medicine The safety and quality of abortion care in the United States. The National Academies Press, Washington, DC2018Google Scholar patients who obtain abortions late in pregnancy have increased risks of complications, few providers, and high costs. Research findings show that carrying an unwanted pregnancy to term is more dangerous to a woman's health than abortion,4Gerdts C Dobkin L Foster DG Schwarz EB Side effects, physical health consequences and mortality associated with abortion and birth after an unwanted pregnancy.Womens Health Issues. 2015; 26: 55-59Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar especially for patients with conditions that increase the health risks of pregnancy, such as hypertension and diabetes. These conditions are more prevalent in low-income women and women of colour—the population most likely to depend on Title X providers. The proposed regulation also violates the fundamental principle of justice in health-care provision. Implementing this rule would create a stratified system in which access to information to make fully informed medical choices is a benefit conferred upon those with the means to afford it. The harm of denying referrals exceeds basic unfairness; it has the potential to drive low-income patients further into poverty. Compared with women who received abortion care, women denied a wanted abortion had four times greater odds of being below the Federal Poverty Level.5Foster DG Biggs MA Ralph L Gerdts C Roberts S Glymour MM Socioeconomic outcomes of women who receive and women who are denied wanted abortions in the United States.Am J Public Health. 2018; 108: 407-413Crossref PubMed Scopus (109) Google Scholar This rule also forfeits patient autonomy. Doctors have an ethical responsibility to advocate for their patients when “proposed policies concerning health care access and quality” conflict with the doctor–patient relationship and the provision of safe, evidence-based care.1American Medical Association Council on Ethical and Judicial Affairs Code of Medical Ethics. American Medical Association, Chicago, IL2016Google Scholar Large medical organisations like the AMA and the American College of Obstetricians and Gynecologists have objected to the proposed regulation. The US Department of Health and Human Services is accepting public comment on the draft rule until July 31, 2018. Providers can also stand with the patients who would be affected by this regulation by signing the Providers Fighting for Title X pledge that reaffirms our commitment to protecting the integrity of the patient–provider relationship. Doctors should speak out and be the voices their patients need. We declare no competing interests.