Rural Plastic Surgery and Conscientious Monopolies: Ethical Barriers to Gender-affirming Care
Year: 2024
Type: article
Abstract: Under federal law, healthcare providers are entitled to invoke conscientious objection (CO) to most professional duties that violate their ethical and religious values. CO is often applied to controversial services such as abortion and physician aid-in-dying. However, in the field of plastic and reconstructive surgery, gender-affirming surgery (GAS) for transgender patients presents an evolving ethical dilemma, where CO is cited with relative frequency.1 Prior findings show 23.5% of rural primary care physicians are unwilling to provide gender-affirming hormone therapy.2 Although a study of this nature regarding GAS has yet to be conducted with rural plastic surgeons, these findings suggest a potential underlying sentiment among rural providers as a whole regarding gender-affirming care. In extreme cases, the collective use of CO by providers can result in a conscientious monopoly (CM). CMs have been described as “the phenomenon in which the CO of a particular medical service leads to the prohibition of such service for the community at large.”3 Typically, CMs are rare and difficult to establish as a collective moral objection among all providers in a given area to a controversial service must be present. A single provider’s willingness to provide a contested service could break such a monopoly and alleviate the barrier in access to care imposed by a CM. Therefore, the likelihood for the establishment of a CM is a function inversely related to the number of providers offering a service. In rural areas, there is a significant shortage of plastic surgeons. Moreover, the low population density in these communities often cannot support multiple plastic surgeons. As a result, if a rural plastic surgeon objects to providing GAS, a CM for that service is likely to form. This issue is further complicated by entire healthcare institutions invoking CO, regardless of the individual providers’ willingness to offer the service. For example, in more than 50 rural communities in the United States, Catholic hospitals are the sole providers of acute short-term care.4 These hospitals follow the Ethical and Religious Directives created by the US Conference of Catholic Bishops, which restrict various legal procedures within their facilities. Even if a plastic surgeon works independently of an objecting institution and is willing to perform GAS, rural areas often lack the infrastructure outside the hospital setting to provide GAS. The intention here is not to encourage plastic surgeons to perform procedures that conflict with their values but to raise awareness of LGBTQ+ challenges in rural areas. Additionally, plastic surgeons should consider utilizing the people versus procedure distinction when evaluating the merits of CO.5 For example, if a plastic surgeon offers cosmetic breast augmentation to cisgender but not transgender female patients, the use of CO could reasonably be viewed as discrimination, because the group requesting care, not the care itself, is the grounds for refusal. Moreover, to help address some of the barriers to GAS in rural communities, plastic surgeons and institutions that object to GAS could consider giving patients advanced notice of the services they object to. Additionally, they could assist patients by referring them to a plastic surgeon willing to provide GAS. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
Authors: Forrest Bohler, Lily Bohler
Institutions: Oakland University, Montana State University
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,195
OpenAlex ID: W4404141347