Respectful Insolence

A physician’s obligation

I’ve written about the corrosive effect that religion can have on medical care when it is allowed to become too pervasive. One example where the intersection of religion and medicine concerns me is when various religious doctors insist on very dubious evidence that religiosity is good for a patient’s health and that physicians should therefore take a “spiritual history” of all of their patients, with one even going so far as to claim that “excluding God from a consultation should be grounds for malpractice.” I’ve also critically discussed studies that purport to show various benefits of prayer, particularly in cancer patients. It figures that, while I was away in Phoenix, there would be a large study published in the New England Journal of Medicine on a topic that should be of great interest to many surgeons: What is the obligation of a physician to inform patients of medical options that the physician personally finds morally objectionable? This is the sort of question that comes into play more and more often; examples include emergency contraception (the “morning after” pill, which some pharmacists have refused to dispense), termination of nutrition and hydration (as in the Terri Schiavo case), abortion, physician-assisted suicide, and terminal sedation in the case of patient dying of an incurable cancer. These questions are truly difficult and passionately argued.

Basically, a group from the University of Chicago surveyed 2,000 practicing physicians on their attitudes regarding their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for religious or moral reasons.

The conclusions of the study from the abstract:

Results: A total of 1144 of 1820 physicians (63%) responded to our survey. On the basis of our results, we estimate that most physicians believe that it is ethically permissible for doctors to explain their moral objections to patients (63%). Most also believe that physicians are obligated to present all options (86%) and to refer the patient to another clinician who does not object to the requested procedure (71%). 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 (multivariate odds ratios, 0.3 to 0.5).

Conclusions: Many physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures. Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests.

If we look at the study in a little more detail, a number of interesting additional observations come out, besides the conclusion that 14% of physicians do not feel obligated even to disclose legal and viable medical options that they consider morally objectionable. For one thing, the true number reported was 8%, with 6% undecided over whether the physician has an obligation to present all possible options to the patient. That’s a little better. On the other hand, only 71% stated that a physician who has a moral objection to a course of treatment that a patient desires to request is obligated to refer the patient to a physician who does not share that objection. Not surprisingly, the number of physicians who believed that physicians are obligated to disclose all options was inversely related to the religiosity of the physician. Of those scoring high on the intrinsic religiosity scale, 19% did not think that physicians are obligated to disclose all possible treatment options while among those scoring low on the intrinsic religiosity scale, only 8% held this opinion; for the question about whether physicians are obligated to refer the patient, only 56% of highly religious physicians agreed that physicians are obligated to refer the patient, while 82% of physicians of low religiosity agreed. A similar inverse relation was found for these variables when compared with the frequency of attendance by the answering physicians at religious services. Not surprisingly, male physicians were also the least likely to disclose or refer if they had a moral objection. Or, as Dr. Bernstein put it:

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.”

Or, from my perspective, what this study reveals is that as many as 14% of physicians do not feel ethically obligated to disclose all possible treatment options if any of those options conflict with their personal religious or moral beliefs, and 29% do not feel obligated to refer to another physician. Virtually all these beliefs are based on the physician’s religion, and here’s where the conflict comes in. What if a patient does not share the physician’s religion? The issue of birth control perfectly encapsulates this problem, if you imagine a devoutly Catholic physician being approached by a patient who is not Catholic and does not subscribe to the Catholic Church’s teachings wanting birth control or emergency contraception? Should a Catholic physician or a fundamentalist Christian physician be given carte blanche not to inform a patient about a legal procedure simply because his or her religious beliefs consider it a sin, particularly when many religions do not?

Another point to be considered is that 63% of physicians consider it ethical to “plainly describe to the patent why he or she objects to the requested procedure.” On this issue, I’m a bit more ambivalent. On the one hand, how can a physician not inform a patient of his or her moral qualms over a course of treatment? On the other hand, as much as we physicians bemoan our diminished status and authority, there is still a deep wellspring of respect for us among most people, and our opinions still matter. Our informing patients of our moral qualms about procedures that, while perhaps controversial, are still considered legal and, by a significant proportion of the population, morally acceptable risks excessive paternalism. Even after having been in practice as an attending for nearly eight years and having been treating patients for 19 years, it still amazes me how much deference patients will show to our opinions as physicians. We physicians have a lot of influence with our patients; in fact, we have an almost scary amount of power. Even without active intent, we can influence patients through even attitudes and body language when discussing various treatment options We tend to forget that. And the more religious a physician is, this study suggests, the more likely he or she is to withhold form the patient the most important ingredient to good shared decision-making with regards to health care: information. This is an effect of religion that is every bit as pernicious as insisting on a “spiritual history” for a patient who may not need or want one. Telling a patient that your personal religious beliefs are such that you cannot in good conscience recommend or participate in a course of treatment is one thing, but not even informing the patient of the option because of your religious beliefs is paternalistic and robs the patient of autonomy.

What we as physicians have to remember here is that we exist to serve the patient. Although we are morally obligated to provide the best care and to provide for our patients the best medical advice that we know how, we have to be willing to acknowledge and accept that our our religious beliefs may not be our patients’ beliefs. When our personal religious or moral beliefs come in conflict with those of our patients, that cannot serve as a reason not to inform the patient of all the medically acceptable options that exist. Although we are morally obligated to provide the best care and to provide for our patients the best medical advice that we know how, we have to acknowledge that our religious beliefs should not be used to prevent patients from pursuing courses of treatment that we may find morally objectionable. Physicians who cannot do that should either not be in areas of medicine where they are likely to encounter such conflicts or they should not be physicians at all.

Comments

  1. #1 quitter
    February 12, 2007

    I just blogged it too.

    I think it’s a sad day when you have to worry your doctor is making moral judgments about your care and your life. However, one critical flaw of the study, they did not give a break down by specialty!

    This study only indicates a serious problem if a substantial number of these docs are in primary care or in OB/GYN. However, if the moralistic assholes realized they couldn’t do their jobs properly in these disciplines and instead chose, derm, or orthopedics, or psych, or path, or any of a dozen other specialties then it’s not a big deal.

    You can be a doctor and think stupid moralistic things in many specialties and there will be no conflict. It’s a bad sign that so many doctors don’t have a better sense of professional ethics, but at least they might have removed themselves from situations in which they might behave in an inappropriate manner.

    I suspect, however, that this is not the case, and primary care and OB/Gyn have just as many of these jerks as the other specialties. As a professional they simply should know better though. It’s not your job to make these decisions for other people. It’s your job to be a doctor. Don’t like it? Don’t be a doctor. There’s no right to be a doctor and then practice bad medicine. Medicine is a profession and it is a privilege to practice, not a right.

  2. #2 Melissa G
    February 12, 2007

    My most scary experience was when I found my two-year-old needed extensive dental work requiring him to be anesthetized. The dentist had a deal with a local Christian-denomination hospital that would work with us to finance the procedure, which we really needed as we were uninsured at the time.

    The scary part came in when we were checked in and I was there waiting for my little boy to receive anesthetic, to which I had no idea how he would react, as he has a family history of sensitivity, and the roving chaplain-type entity came in asking if we wanted literature and whether we wanted her to pray with us.

    I just wanted her to leave us alone, but I found myself deathly afraid that if I told her we were atheists, she would put some kind of scarlet letter A in our records and it would affect the quality of our care. I shut up and took the literature and told her we pray privately. It did nothing but compound my stress.

    I feel that such hospitals exploit the emotional vunerability of the patient and family. Although we received top-notch care there, I would never, ever go back to a hospital with a religion in the title if I have any say in the matter.

  3. #3 Blake Stacey
    February 12, 2007

    This study only indicates a serious problem if a substantial number of these docs are in primary care or in OB/GYN. However, if the moralistic assholes realized they couldn’t do their jobs properly in these disciplines and instead chose, derm, or orthopedics, or psych, or path, or any of a dozen other specialties then it’s not a big deal.

    A fine point, but I’m not so sure “psych” should be on that list.

  4. #4 Hurly
    February 12, 2007

    Copied from NHS Blog Doctor
    “Mrs Taylor’s solicitor Richard Stein of Leigh Day & Co Solicitors, said: “We have advised our client that she is entitled to seek this treatment and that it is unlawful for doctors to deny it to her unless they also take steps to find a doctor willing to provide it for her.”
    If, finally, it is Kelly’s decision that life is intolerable, that she must end it, then it is outrageous to expect that some doctor should be compelled to kill her. Whatever the courts decide about her human rights, she should remember that doctors have human rights too. No doctor can be compelled to kill patients and she will have difficulty finding a reputable British doctor to kill her voluntarily.
    “I think it’s a sad day when you have to worry your doctor is making moral judgments about your care and your life.

    Well Mr. Quitter. Or maybe “moralistic asshole” as you’ve called me
    There are some patients I will not see, nor will I refer them. It is my right to choose who I work for and under what circumstances I am willing to do that work.

  5. #5 Orac
    February 12, 2007

    But will you withhold information about specific medical treatments from your patients if you deem them to be against your “moral code”?

  6. #6 Hurly
    February 12, 2007

    But will you withhold information about specific medical treatments from your patients if you deem them to be against your “moral code”?

    I may not “withhold information” depending on what you mean by that(ie;how to kill myself with medicines). I may say that there is a medical treatment for this, but you will have to talk to another provider about it, because I don’t do it, so do not know very much about it.

    I certainly may refuse to treat them or refer them. ie; I will no longer see you as a patient. You must find another provider. Here is a yellow book.

    Maybe the provider you want to refer to does not want to do whatever either. I don’t interrogate my peers about their moral code

  7. #7 DuWayne
    February 12, 2007

    Count me as one who would love to have fairly strong trust in doctors that I might have to deal with. For me, I don’t care what field they are in, if they feel that it is ok for a doctor not to inform patients of procedures they dissagree with – they cannot be trusted. I think it is a serious problem.

    I do not want to spend time learning what options are available to me, the patient. I want to trust my doctor to inform me of every option available – not just those s/he finds morally acceptable. I have no problem with them telling me why they dissagree with it, I do have a serious issue with them deciding not to inform me at all. They should also make sure that I can find someone to perform such a procedure, if they refuse.

    I think doctors need to understand that patients place such strong faith in them, because the human body is so complex and, in many ways, mysterious. People need to believe that their doctor is taking the best care of them, they could possibly get. They need to know that their doctor is giving them every reasonable option. I think this is what makes alties so fanatical. They believe that the “EBM establishment” is betraying that trust, by not giving them all the options (yes, their front end belief is irrational – but I think the underlying feeling of betrayal is a good comparison).

    I know that I have a certain awe, for those who have spent the time and energy to learn about how to keep me healthy. I take very seriously, everything doctor tells me – because they went to med school, so I wouldn’t have to. Things like this upset me, because I want to be able to have that trust in doctors.

  8. #8 quitter
    February 12, 2007

    Hurly, you are a moralistic asshole. Sorry to be the one to tell you.

    It is not your right to deny care to patients just because they disagree with you. Maybe you need a brush-up on your professional ethics?

    As part of the package of ethics you agreed to abide by when you became a doctor and by the rules of your professional association (they’re similar across most of the different boarding organizations), you can not just choose not to treat people without referrals or without damn good reason. For instance, you can’t choose not to see medicaid/medicare patients, you can’t choose not to see black people, or women. Go look at your ethics guidelines. And if you had a patient who you’ve seen previously and you disagree with what they want to do with their bodies, if you don’t refer them, that’s not the standard of care, that’s abandonment, and just bad professional ethics. If I suspected a doctor had done this to me I would tell the state board of physician quality assurance that they refused to refer for a legitimate medical inquiry.

    Now, as far as “killing” patients, it’s not the doctors job to kill them, although they do prescribe lethal doses of medication. And at least there is something of a legitimate medical ethical argument to be made, that you swore to “do no harm” and you’re interpretation of that to mean not providing lethal doses of medication is professionally reasonable. I could see a legitimate medical debate on that.

    But “do no harm” does not mean “protect their immortal soul” or “impose your beliefs” on patients. Face it, we’re talking about abortion/contraception here, not the right-to-die stuff that exists only in one state in the union.

  9. #9 anonimouse
    February 12, 2007

    quitter,

    While I agree with what you say, how does this statement…

    And if you had a patient who you’ve seen previously and you disagree with what they want to do with their bodies, if you don’t refer them, that’s not the standard of care, that’s abandonment, and just bad professional ethics.

    …jibe with the idea that if a patient refuses to follow your orders or chooses to engage in woo (like parents who won’t vaccinate their kids or would rather take herbal remedies instead of chemo) a doctor should have the right to terminate the physician-patient relationship.

    Are you talking about patients who wish to engage in a treatment that’s within the normal standards of care and the physician refusing to assist with that treatment and subsequently refusing to refer the patient to an appropriate physician?

  10. #10 Hurly
    February 12, 2007

    Quitter,
    Yes I do have the “right” not to see medicaid/medicare patients if I’m willing to forgo government subsidies. Also I can most certainly tell you I will no longer see you as long as I go thru the hoops(letter, wait 30 days, list of providers((yellow book)), I don’t even “need” a reason why. I can refuse to see children, women ,men basically anyone I want as long as it is not an emergency situation, (What about pediatricians don’t see adults, ob/gyn don’t see men, etc)

    But “do no harm” does not mean “protect their immortal soul” or “impose your beliefs” on patients.
    I’m not trying to impose my beliefs on them(I’m an atheist) but I am not going to allow them to impose thier beliefs on me. As far as abortion goes, I’m not in that field and actually I know of no one who is, so I couldn’t advise or refer if I wanted to. Contracetion is not a problem with me. I’ll write them scripts.

  11. #11 quitter
    February 12, 2007

    Ah, if you have the luxury to be completely fee-for-service I suppose you could get away with that. For those who actually need medicaid/medicare to survive a restriction on those patients I know is explicitly illegal.

    I’m pretty sure that most boarding organizations do not allow sex or racial discrimination as part of you getting boarded though, nor is age discrimination considered ok. I’d look into that before instituting a policy against anyone for any reason. The problem is that these are professional organizations and they can make the rules to be whatever they want as far as discriminating. You may think you have some absolute right to see who you want, but this is probably not the case according to your code of professional ethics.

    …jibe with the idea that if a patient refuses to follow your orders or chooses to engage in woo (like parents who won’t vaccinate their kids or would rather take herbal remedies instead of chemo) a doctor should have the right to terminate the physician-patient relationship.

    Are you talking about patients who wish to engage in a treatment that’s within the normal standards of care and the physician refusing to assist with that treatment and subsequently refusing to refer the patient to an appropriate physician?

    If parents won’t vaccinate their kids or want to experiment with them as part of their belief in woo (which seems to be what they love to do – it would be grossly unethical for a doctor to do what some of these parents do) the doctor can counsel them that they’re crazy, but certainly can’t force them to do anything. As far as referral to an “appropriate physician” who prescribes woo, is that like a witch doctor?

    It’s not in the realm of evidence-based medicine to “prescribe” alternative treatments. If they want a medication that is not indicated by the evidence, or if the prescribing of that medication is a standard of care violation, they’re shit out of luck. You are not a burger flipper, and the customer is not always right, nor is it your job to write prescriptions for stuff that’s OTC anyway and medically unproven.

    If there is a viable medical alternative with evidence backing it up, it’s your job to know about it and help them get it if they like. But this doesn’t cover alties, they can’t demand doctors start prescribing quack remedies and patent medications, that would also be a violation of professional ethics (I think the AMA should go back to being a quack-busting organization).

  12. #12 Chris
    February 12, 2007

    I think this is what makes alties so fanatical. They believe that the “EBM establishment” is betraying that trust, by not giving them all the options (yes, their front end belief is irrational – but I think the underlying feeling of betrayal is a good comparison).

    Indeed – they want all the options, and that arrogant paternalistic doctor only wants to provide the options that are proven safe and effective. How dare they!

    The difference is, doctors have specialized training in determining which treatment options are safe and effective. They do not have specialized training in determining which treatment options are moral; therefore they have no basis to speak with authority on that subject and shouldn’t try to impose their own opinion of the moral issue over the patient’s.

    It’s possible that somewhere in the world there is someone who is both a doctor *and* a professor of moral philosophy. But most doctors aren’t, and it’s unreasonable to expect them to be; they have quite enough to learn as it is! Your doctor’s pronouncements on morality carry just as much weight as your doctor’s pronouncements on car repair (unless of course your doctor happens to moonlight as a mechanic), but not everyone sees it that way and thus doctors should be careful not to throw their weight around when they’re outside their area of expertise.

    But hey, that’s just a layman’s opinion.

  13. #13 Joseph Hertzlinger
    February 12, 2007

    If I were a physician, I would be dubious about recommending that patients get organ transplants in an area where executed criminals are used as a source of parts.

  14. #14 madhusree
    February 13, 2007

    The post and all the comments made for a thought provoking read. To provide for informed consent for therapy, it is essential that the clinician gives as much relevant information about different treatments as they know how to, otherwise they are failing in their duty as a practitioner. If you can’t take the heat…..

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.