Dr. Joanna Stacey, who has a small practice at Carilion Gynecology in Roanoke, has made a conscious decision never to perform an abortion.

Salem oncologist William Fintel counsels about one patient a year against the idea of physician-assisted suicide.

John Reuwer, an emergency room doctor at Carilion New River Valley Medical Center, said when women come in for emergency contraception -- even in the case of sexual assault -- and he is the only doctor on duty, he will refer the case to another doctor who has less of a problem dispensing what is commonly known as the morning-after pill.

Faith and values, and their implications, are factors in emergency rooms, family practices, residency programs, hospital bioethics committees and operating rooms in the Roanoke and New River valleys.

Issues of conscience are coming up increasingly as medical developments in reproductive technology and at the end of life raise ethical concerns. Some of the doctors interviewed for this story said they make decisions based on their conscience about issues such as emergency contraception, referrals for abortions and end-of-life care.

"It's critical that society in general not require their employees to violate their conscience in any aspect of their job," Reuwer said.

Stacey, Fintel and Reuwer are members of the Christian Medical & Dental Associations. With 17,000 members, it is the largest faith-based organization of doctors in the United States. The organization has 180 members in Virginia, about a dozen practicing in the Roanoke and New River valleys.

The organization, headquartered in Bristol, Tenn., has been at the forefront of many of the ethical debates facing the medical community -- including the right of health care workers to refuse to perform medical procedures they object to on moral or religious grounds.

The right of conscience has recently made headlines. Pharmacists in Illinois have sued Walgreens for firing them for not dispensing emergency contraception. Anesthesiologists in California have refused to participate in an execution.

Dr. Stephen ReMine, director of surgical education for Carilion Health System, described the right of conscience as "a very powerful issue in medicine."

"Most of us come into medicine with that bias -- we are coming into medicine to preserve life," ReMine said.

The Christian Medical & Dental Associations have position statements on medical issues based on biblical ethics. They are grounded in the belief that all life is created in God's image and is sacred.

The statements oppose abortion, embryonic stem cell research and euthanasia; take a nuanced view toward reproductive technologies such as in vitro fertilization; advocate for care for the poor; and maintain that sexual intercourse should be reserved exclusively for married, heterosexual couples.

Many local members of the organization said they look to the organization for guidance on medical issues.

But some people question whether patients are ill-served when health care providers make decisions based on their conscience.

"You better have somebody seeing sexual assault victims who is willing to provide emergency contraception," said Janet McDowell, director of education for Planned Parenthood of the Blue Ridge and a medical ethicist who consults for local hospitals.

She pointed out that part of what makes emergency contraception so critical is that it is time sensitive. She questioned whether it is patient abandonment to say, 'You want emergency contraception? I won't give it to you.' "

Kent Willis, executive director of the American Civil Liberties Union of Virginia, said that in an ideal world, patients could receive all services that are medically available to them, and doctors and other health care providers could refuse to render some services based on moral or ethical principles.

But he said the problem is that patients are left at a disadvantage if a health care worker doesn't provide complete information.

"At the very least, it is imperative that medical professionals make it very clear up front what their limitations are, so patients understand they are not necessarily receiving complete information," Willis said.

Policy and procedure

Health care providers generally do not have to engage in practices that offend their own scruples or conscience, said Ann Massie, a professor at Washington & Lee Law School who specializes in bioethics.

The issue usually comes up with respect to providing abortions and also care at the end of life, Massie wrote in an e-mail.

In Virginia, a doctor has the freedom to choose who he or she will treat, except in the case of an emergency, said Dr. William Harp, executive director of the Virginia Board of Medicine.

If a doctor and a patient reach an impasse over care, the doctor needs to ensure continuity of care. But there is no legal requirement that the doctor refer the patient to a specific physician or provide a list of doctors with whom a patient could seek care.

Should a health care provider decide not to treat a patient, however, a claim of abandonment could arise, according to a Roanoke attorney who specializes in health law.

"The risk is that a physician refusing to do a procedure could be accused of patient abandonment. This puts a premium on notifying the patient in adequate time to find another doctor," said Heman Marshall III.

HCA Hospitals of Southwest Virginia, which owns Lewis-Gale Medical Center, and Carilion Health System have policies on health care workers' right of refusal.

Carilion's policy says that the system acknowledges and respects employees' individual beliefs and makes provisions for accommodating those beliefs "where it is also possible to secure the ultimate safety and protection of employees, patients, and visitors."

Potential employees must disclose their reason for refusing care and request accommodation at the time of employment.

The policy specifically mentions that employees who have an objection to performing abortions on personal, ethical, moral or religious grounds who have stated their objection in writing will not be disciplined or subject to recrimination.

Carilion does not provide elective abortions, nor does Lewis-Gale Medical Center.

HCA's policy asks employees to anticipate situations where procedures would interfere with someone's religious, moral, ethical or cultural values and contact their supervisor about any request for accommodation.

The request then goes through a formalized review process.

The policy states that the Department of Human Resources will consider whether the request would negatively affect patient care or the functioning of the unit; whether an alternative approach could be used; what affect the accommodation might have on staffing; and whether, if it is a constant conflict, other employment should be considered.

Carilion spokesman Eric Earnhart wrote in an e-mail that the system's emergency rooms do dispense emergency contraception in sexual assault or rape cases.

If a doctor or staff member has an ethical issue with dispensing emergency contraception, the case would be transferred to another staff member and the request fulfilled, Earnhart said.

Nancy May, a spokeswoman for HCA, wrote in an e-mail that "acute sexually assaulted patients who are of childbearing age are only provided with an emergency contraception kit after they have had a negative pregnancy test."

"This prescription is to keep the patient from becoming pregnant -- not ending a pregnancy," May wrote.

The issues

The right of conscience typically plays out at the beginning and end of life.

The question of whether future doctors plan to learn how to perform an abortion comes up early in their medical careers.

Dr. Robert Dums, who did his residency at Carilion, said he and other residents chose not to perform abortions.

Dums, who now practices at Carilion Family Medicine in Shawsville, also said "there are certain doctors in Carilion who don't believe the way I do, and that's fine. Everybody has to make their own decisions."

Dr. Steven Ridout, a family practitioner with Lewis-Gale Clinic Family Practice in Bonsack, said in the case of a pregnant teen, he would talk to her parents, refer them to an obstetrician so they can see ultrasound pictures, and give them an 800 number for a crisis pregnancy center.

"I make it clear to them that I want them to choose life for their child," Ridout said. "And I make it clear that if they choose an abortion, they're still welcome in this office."

McDowell, meanwhile, is concerned that patients are being given selective information.

At Planned Parenthood, she said their obligation is to share the information with a newly pregnant woman that she can keep the baby, give it up for adoption, or terminate the pregnancy.

"I don't know that every practitioner that provides pregnancy tests provides that information," she said.

Mona Barringer of the Roanoke Medical Center for Women, which provides elective abortions, said she sees "a lot of hypocrisy" with respect to abortion.

She said there are two schools of thought on abortion.

"That it's totally wrong, or that God is understanding and forgiving and is going to help you through this," she said.

The other arena where a health care workers' right of conscience can play out is at the end of life.

"Our job as physicians is to make that transition from this life to the next as easy and as pain-free as humanly possible," said Keith Stephenson, a surgeon at Carilion Surgical Associates in Blacksburg and a member of the Christian Medical & Dental Associations. "But that doesn't mean actively hastening their demise."

All the doctors interviewed for this story -- whether members of the Christian Medical & Dental Associations or not -- said they opposed euthanasia or physician-assisted suicide, which are not legal in Virginia. But some differed on certain aspects of how much care is appropriate at the end of life.

Fintel said toward the end of life, a comfortable end can be achieved with a combination of narcotics and a tranquilizer such as Valium, he said.

"The intent is to ease suffering ... and not to cause the death," he said.

Problems arise when patients have not made their wishes clear in legal documents such as advance directives and living wills.

McDowell said there have been instances of families in the Roanoke Valley who did not know in the case of a relative that their doctor was opposed to taking someone off a ventilator.

"The time to learn that is not when you're in a crisis," McDowell said.

She recalled one case that came before a local hospital ethics committee in which a family wanted a feeding tube put in for a patient who was frail, elderly and had dementia.

But the medical team didn't think it was a wise thing to do and discussed why with the family.

"Once they understood what they were hearing, we came to some consensus," McDowell said of the patient's relatives. "What they needed to hear was, 'so we've done everything we can?' "

She suggested patients ask doctors about their beliefs and discuss how they could affect patient care.

"It's a matter of matching patient expectations and the provider's expectation," McDowell said.