“Not My Cup of Tea But Should I Offer It to My Patient?”
I have posted on this blog a number of times the issue of how healthcare providers including pharmacists should react to patients who request services or medications against which the professionals have strong moral or ethical feelings. Examples of such requests would be abortion, emergency contraception, contraception to minors without parental permission, termination of nutrition and hydration, terminal sedation and others. In the public discussion within the media, the public and even ethicists have taken both sides on the issue of whether a doctor’s conscience about providing legal services or medications should play any part in the delivery of modern medical care. What hasn’t been researched well is what is the opinion of physicians themselves on this issue.
It was therefore rewarding for me to read an article in the current Februrary 8, 2007 issue of the New England Journal of Medicine by Farr A. Curlin, M.D. and others who presented the results of their study of 1820 physicians in an article titled “Religion, Conscience and Controversial Clinical Practices”. They found that 63% of the doctors that participated in the survey expressed the opinion that it was ethically permissible for doctors to explain their moral objections to the patients. Eighty percent said that physicians are obligated to present all options to the patient and 71% agreed with the concept of referring the patient to another physician who did not object to the requested procedure. Reviewing the demographics of the participants disclosed that “physicians who were male, those who were religious and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds.”
Although, the study revealed only what physicians said about the issue and not whether they actually practiced what they said. Nevertheless "if the physician's ideas translate into their practices, the 14% of patients--more than 40 million Americans--may be cared for by physicians who do not feel they are obligated to disclose medically available information they consider objectionable. In addition, 29% of patients--nearly 100 million Americans--may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments." The authors concluded that "patients who want information about and access to such procedures may need to inquire proactively to determine whether their physician would accommodate such requests.” This means, I think, that it certainly would be wise, before selecting a physician, to ask them about how they would respond to these requests by a patient. If the patient was unsatisfied with the physician’s response, another physician should be sought.
Have any of my visitors interviewed a physician with regard to their moral opinions and practices before selecting that physician as ones personal doctor? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:07:00 AM
9 comments
9 Comments:
There's also the case where a patient might not know about a therapy that could solve a problem, and so not know to ask.
For example, birth control pills can help women with painful periods, etc. Women aren't born knowing that, however; so if a woman goes to her doctor complaining of painful or irregular periods, and the doctor doesn't believe in using any sort of birth control, that woman isn't going to even learn about the possibility.
She may know about birth control as birth control, but if she's looking for period or pain control, she wouldn't necessarily know to ask about birth control pills.
I bet there are lots of other examples where regular Joe's don't know about potentially helpful things their doctor may not believe in using for unscientific reasons.
I am not sure how a physician who was against prescribing a contraceptive pill for contraceptive purpose would look at the prescription of a contraceptive pill for a non-contraceptive function but where the incidental side-effect of the treatment would be contraception. Some decisions by physicians regarding the ethics or morality of the consequences of their decisions may be tolerable since the matter of intent is the rationalizing factor. The intent is one of the factors in the "double effect" rationalization, for example, if a terminally ill patient in pain requires high doses of narcotics that could lead in some patients to a premature death from the narcotic. ..Maurice.
I think some of these "conscientious objector" physicians (and pharmacists) are on firmer ground than most people realize. If you look at the specific interventions about which they were polled, you might notice that they tend to fall outside the scope of medical indications. In such circumstances, it's pretty difficult to construct a cogent argument that there is a _professional_ obligation to provide or refer.
Bob, first I want to apologize for not being more specific regarding the details of the study. According to the authors, "the primary criterion variables were physicians' responses to the following three questions: 'If a patient requests a legal medical procedure, but the patient's physician objects to the procedure for moral or religious reasons, would it be ethical for the physician to plainly describe to the patient why he or she objects to the requested procedures? Does the physician have an obligation to present all possible options to the patient, including information about obtaining the requested procedure? Does the physician have an obligation to refer the patient to someone who does not object to the requested procedure?'" ..."To determine whether physicians' judgments about their ethical obligations are associated with their views on controversial clinical practices, we asked the survey respondents whether they have a religious or moral objection to terminal sedation (administering sedation that leads to unconsciousness in dying patients), abortions for failed contraception, and the prescription of birth control to adolescents without parental approval" As you see the statistics I described applied to the three primary criterion variables and not to any specific clinical practices. Whether even the mentioning the three specific practices in the survey affected the response to the primary variables, I think is certainly a possibility.
Bob, I can see your point about "provide or refer", though I still might have some uncertainties, however with regard to inform, I wonder if all doctors must bear that professional responsibility. Educating the patient regarding the medical facts should be unrelated to a physician's moral or ethical views. ..Maurice.
Maurice - I hadn't intended my earlier comment as a criticism of anyone, just an effort to raise a consideration that I think is relevant to the issues here. Surely the obligations of a physician regarding a particular intervention should be sensitive to whether or not it serves a medical purpose. I think your reference earlier to "double-effect" and the physician's medical intent reinforce the relevance of medical indications.
A procedure can be a "legal procedure" but simply not considered medically appropriate by a physician in it's very nature. My state might legalize euthanasia. It would then become a legal procedure that utilizes medical technology and skills, yet I would not consider it to me "medically appropriate" because it has never been and is not part of Hippocratic medicine to kill people. While the law may facilitate or impede me practicing within my professional ethics, it does not define them. This is recognized by the general consensus on the ethics of physician's actively acting in executions, although legal.
I do not feel ethically obligated to discuss the option of abortion in the same way. While, by judicial fiat, it is legal, it is not, in my view, part of Hippocratic medicine to perform abortions for family planning, and I do not personally consider medical doctors who perform abortions for contraception to be a member of this profession. Why would the morality of a matter change with a court decision? Why would I suddenly be obligated to facilitate what I was previously prohibited from doing and took an oath to avoid? Did killing mentally retarded people become an option that physicians were obliged to discuss with families when the Third Reich made it legal?
To Anonymous from today February 14, 2007: When one is deciding if education of the patient concerning a procedure which is legal and represents the professionally current standard of care but personally is not acceptable on moral grounds, one has to consider to whom the education is to be rendered. What I mean is whether the scenario is one neighbor talking to another neighbor over the fence about such a procedure or whether it is a physician speaking to his or her patient over the office desk. In the former case, the one neighbor has no fiduciary responsibility to tell the neighbor anything if that anything is personally morally unacceptable. In the case of the physician-patient relationship, I would say that morality has nothing to do with a professional education and discussion with the patient of professionally acceptable options. It is the doctor's responsibilty to disclose all the options which are available to the patient and even where they might be obtained if the physician is unable to provide them. Of course, part of the education is to inform the patient of the physician's biases and moral views and to explain (not proselytize) the physician's rationale for not advising the particular option. It could be that the physician's moral view might be accepted by the patient. It could be that the patient will look for help elsewhere. I think it is the duty to inform, regardless of the personal morality of the procedure, that is the physician's professional requirement. ..Maurice.
Maurice - You seem to be arguing that physicians have a professional responsibility to inform patients about "all options," even options that lack any firm medical rationale. So supposes someone approaches a surgeon with a request to amputate a healthy limb... Does the surgeon have a professional obligation to inform this individual of the various ways to accomplish this end?
Bob, I think you misread my opinion. I wrote "When one is deciding if education of the patient concerning a procedure which is legal and represents the professionally current standard of care but personally is not acceptable on moral grounds,..." and "I would say that morality has nothing to do with a professional education and discussion with the patient of professionally acceptable options." I would think it would be irresponsible for a physician to encourage a cancer patient to find a source of Laetrile in Mexico and that this drug "might present the patient's last hope for recovery". I say physicians have a professional responsibility to inform patients about all the options which are legal and accepted professional standards of care. There is no doubt that there might be disagreement amongst physicians as to what is "accepted", but if there are no evidence-based studies available to prove otherwise and there is reasonable consensus of value by the medical community, I would say, with careful consideration of the specific clinical state and goals of the patient, such procedures or treatments should be given to the patient as an option. ..Maurice.
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