Sometimes I feel like I’m pounding my head against a wall. I’ve been wondering why the issue of so-called conscience clauses just won’t die, why otherwise intelligent people
can’t just agree with me just don’t get it.
Quick review: some health care professionals wish to be able to deny patients certain types of care, and want to be protected by law for imposing their own morals on others, in violation of basic medical ethics and human dignity (as you can see, I don’t have a strong opinion about this one).
Ethical behavior is difficult. It requires empathy—but in a very particular sense. It requires someone to be able to see things through someone else’s eyes, to imagine the same events from more than one perspective. Ethics aren’t a blunt object used to impose your will; they are a tool to help elucidate the differences between choices, and to solve problems. Ethics, in short, requires a good imagination.
Some of the arguments that people in favor of conscience clauses provide are based on a fundamental misunderstanding of ethics.
A health care provider is not required to provide any service to any person. She has the right to choose whom to serve and how. Within limits.
For example, in the AMA code of ethics, one of the principles says:
A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
Remember, ethics provide for the dignity of both persons in a relationship. A physician can’t be forced into any relationship…BUT if a physician chooses to deny care to someone, there better be a good reason, and the dignity of a patient must still be respected. So, for example, when a patient calls my office, but I don’t participate in their insurance, my secretary informs them of the problem and offers them the numbers of other practitioners. If the same patient comes to see me, and I don’t properly check their insurance status, it’s too late—I have a deeper ethical obligation, and I need a stronger reason to deny them care. In this case, the reason is that it will cost both me and the patient monetarily to continue the relationship, and we will probably choose together to end it. Ethics is a shared tool, and ethical decisions involve all parties.
Given that ethics provide for the dignity of both people in a relationship, what should we do when a decision appears to inevitably cause a conflict between the needs of both?
This is when we must look at what other duties are implied by the relationship. As a physician I have a responsibility to provide the standard of care to my patients, as far as I am able. If a patient has appendicitis, the standard of care is not for me to remove the appendix, as I’m not competent to do that. The standard of care if for me to send them to the emergency room. If a patient comes to me for contraception, well, I’m competent to provide it, and its provision meets the standard of care. What if I’m morally opposed to it? Personally, I find that abhorrent, but a not-so-horrible second choice is to explain to the patient your general lack of competence in the area (they don’t need to know that your incompetence is due to religious beliefs), and to give them a realistic and timely referral.
Let’s be clear here: we are talking about “standard of care”, not medical necessity. One of my commenters believes that providers (pharmacists in particular) are not required to provide services that are not medically necessary. This is a fundamental misunderstanding. “Medical necessity” is a financial, not medical, concept. An insurance company determines what is “medically necessary” in order to decide what they will or will not pay for. Often enough, what an insurer thinks is not medically necessary is still vital to the patient.
Ethics is hard. It requires imaging a world without you in it, or at least one in which your needs are not paramount. It requires a very “grown-up” perspective. If you can’t behave like a grown up, you shouldn’t be playing with people’s health.