More than a dozen states are considering new laws to protect health workers who do not want to provide care that conflicts with their personal beliefs, a surge of legislation that reflects the intensifying tension between asserting individual religious values and defending patients' rights.
About half of the proposals would shield pharmacists who refuse to fill prescriptions for birth control and morning-after pills because they believe the drugs cause abortions. But many are far broader measures that would shelter a doctor, nurse, aide, technician or other employee who objects to any therapy. That might include in-vitro fertilization, physician-assisted suicide, embryonic stem cells and perhaps even providing treatment to gays and lesbians.
Because many legislatures have just convened, advocates on both sides are predicting that the number debating such proposals will increase. At least 18 states are already considering 36 bills.
"It's already a very hot issue," said Edward R. Martin Jr. of the Americans United for Life, who is advising legislators around the country pushing such bills. "I think it's going to get even hotter, for lots of reasons and in lots of places."
The flurry of political activity is being welcomed by conservative groups that consider it crucial to prevent health workers from being coerced into participating in care they find morally repugnant -- protecting their "right of conscience" or "right of refusal."
"This goes to the core of what it means to be an American," said David Stevens, executive director of the Christian Medical & Dental Associations. "Conscience is the most sacred of all property. Doctors, dentists, nurses and other health care workers should not be forced to violate their consciences."
The swell of propositions is raising alarm among advocates for abortion rights, family planning, AIDS prevention, the right to die, gays and lesbians, and others who see the push as the latest manifestation of the growing political power of social conservatives.
"This is a very significant threat to patients' rights in the United States," said Lois Uttley of the MergerWatch project, who is helping organize a conference in New York to plot a counterstrategy. "We need to protect the patient's right to use their own religious or ethical values to make medical decisions."
Both sides agree that the struggle between personal beliefs and professional medical responsibilities is likely to escalate as more states consider approving physician-assisted suicide, as embryonic stem cell research speeds forward and as other advances open more ethical fault lines.
"We are moving into a brave new world of cloning, cyborgs, sex selection, genetic testing of embryos," Stevens said. "The list of difficult ethical issues involving nurses, physicians, research scientists, pharmacists and other health care workers is just continuing to increase."
Most states have long had laws to protect doctors and nurses who do not want to perform abortions from being fired, disciplined or sued, or from facing other legal action. Conflicts over other health care workers emerged after the morning-after pill was approved and pharmacists began refusing to fill prescriptions for it. As a result, some lost their jobs, were reprimanded or were sanctioned by state licensing boards.
That prompted a number of states last year to consider laws that would r explicitly protect pharmacists or, alternately, require them to fill such prescriptions.
The issue is gaining new prominence this year because of a confluence of factors. They include the heightened attention to pharmacists amid a host of controversial medical issues, such as the possible over-the-counter sale of the Plan B morning-after pill, embryonic research and testing, and debates over physician-assisted suicide and end-of-life care in the wake of the Terri Schiavo right-to-die case.
"There's an awful lot of dry kindling in the room," Martin said.
At least seven states are considering laws that would specifically protect pharmacists or pharmacies.
"Every other day, I hear from pharmacists who are being threatened or told they have to sign something that says they are willing to go along with government mandates," said Francis J. Manion of the American Center for Law & Justice, which is fighting an Illinois regulation implemented last year requiring pharmacies to fill all prescriptions, which led to a number of pharmacists being fired. "The right to not be required to do something that violates your core beliefs is fundamental in our society."
Opponents say such laws endanger patients by denying them access to legal drugs, particularly morning-after pills, which must be taken quickly. They say women often must go from pharmacy to pharmacy to get those prescriptions filled.
"Women all over the country are being turned away from obtaining valid and legal prescriptions," said Jackie Payne of the Planned Parenthood Federation of America. "These kinds of laws would only make the situation worse. It's shameful." Planned Parenthood is supporting efforts in at least six states to pass laws requiring pharmacists to fill all prescriptions.
At least nine states are considering "right of refusal" bills that are far broader. Some would protect virtually any worker involved in health care; others would extend protection to hospitals, clinics and other health care facilities. Some would protect only workers who refuse to provide certain health services, but many would be far more expansive.
At least five of the broad bills would allow insurance companies to opt out of covering services they find objectionable for religious reasons. A sixth state, Pennsylvania, is considering a bill designed for insurers.
"These represent a major expansion of this notion of right of refusal," said Elizabeth Nash of the Guttmacher Institute, a nonprofit organization that studies reproductive health issues and is tracking the legislation. "You're seeing it broadening to many types of workers -- even into the world of social workers -- and for any service for which you have a moral or religious belief."
Supporters say the laws are necessary, given the rapidly changing nature of medical research and care.
"We live in a culture where more and more people are on opposite sides of these basic issues," said Manion, who has represented an ambulance driver who was fired after she refused to take a patient to a hospital for an abortion, a health department secretary who was not promoted after she objected to providing abortion information, and a nurse who was transferred after she refused to provide morning-after pills.
Opponents fear the laws are often so broad that they could be used to withhold health services far beyond those related to abortion and embryos.
"The so-called right-to-life movement in the United States has expanded its agenda way beyond the original focus on abortion," Uttley said. "Given the political power of religious conservatives, the impact of a whole range of patient services could be in danger."
Doctors opposed to fetal tissue research, for example, could refuse to notify parents that their child was due for a chicken pox inoculation because the vaccine was originally produced using fetal tissue cell cultures, said R. Alto Charo, a bioethicist at the University of Wisconsin.
"That physician would be immunized from medical malpractice claims and state disciplinary action," Charo said.
Advocates for end-of-life care are alarmed that the laws would allow health care workers and institutions to disregard terminally ill patients' decisions to refuse resuscitation, feeding tubes, and other invasive measures.
"Patients have a right to say no to CPR, to being put on a ventilator, to getting feeding tubes," said Kathryn Tucker of Compassion and Choice, which advocates better end-of-life care and physician-assisted suicide.
Others worry that health care workers could refuse to provide sex education because they believe in abstinence instead, or deny care to gays and lesbians because they object to their lifestyle.
"I already get calls all the time from people who have been turned away by their doctors," said Jennifer C. Pizer of the Lambda Legal Defense and Education Fund, who is representing a California lesbian whose doctor refused her artificial insemination. "This is a very grave concern."