The Values of Doctors and the Nontreatment of Patients
The media are making a pretty big splash about a New England Journal of Medicine study, which measured doctors' willingness to refuse desired services if it violated their personal moral codes. From the story: "Based on the findings, the researchers estimate that more than 40 million Americans may be seeing physicians who do not believe that they are obligated to disclose information about legal treatments the doctor objects to, and 100 million have doctors who do not feel the need to refer patients to another provider."
The focus, of course, was on doctors who hold what are labeled conservative beliefs, e.g., abortion, contraception, etc. And there is a pretty strong move underway to compel medical professionals (including pharmacists) to perform these services at the risk of losing their jobs or licenses to practice.
But this is a two-edged sword. Futile care theory, which would authorize doctors to refuse wanted life-sustaining treatment based on their own moral code, also would authorize physicians and other professionals to refuse wanted services. Yet, many bioethicists who are the most adamantly against, say, a Catholic pharmacist being allowed to refuse to distribute contraception, are all for futile care theory. Similarly, when I warn pro lifers that creating so-called "conscience clauses" allowing the refusal of some services could also legitimize medical futility, they will often nod their heads and keep on trucking.
I think there are solutions to these moral dilemmas. And I offer a few here: First, if denying the wanted medical service would likely result in death or significant harm to the health of the patient, it should not be allowed to be refused. Example: No doctor should be allowed to refuse to end an ectopic pregnancy, nor provide food and fluids to a patient diagnosed with permanent unconsciousness when that is what the patient/surrogate decision makers want.
For less pressing issues, surely panels of willing professionals can be found to take over a patient's care or provide contraceptive services. And whenever there is a bona fide conscience issue, all should work together to transfer care to a willing professional.
Finally, doctors and health care institutions should disclose their policies before receiving patients into their care. In this regard, for example, I have urged doctors in Oregon to hang plaques in their waiting rooms declaring the office to be an "assisted suicide free zone."
The genius of our system is our ability to accommodate the beliefs of people holding widely divergent moral and political views. Surely, we can work together to generally respect the moral views of medical professionals, without deleteriously impacting pateients' health.
posted by Wesley J. Smith @ 8:59 AM
18 Comments
18 Comments:
OK. That might work in some communities, but not where the options are limited.
For instance, let's say that all the pharmacists of a small town are Catholic and same with the neighboring towns.
In those situations, disclosure of non-contraceptive policy would not help much. Furthermore, some of the pharmacists may feel that it is against their beliefs to even refer someone to place where they can find contraceptives.
what then?
Your hypothetical is very unlikely, it seems to me. But in such rare cases, there is always the Internet, Federal Express,and/or a drive 20 or 30 miles if it comes to that. Feminist groups could create an emergency hotline for Plan B and date rape kinds of situations, etc.
Otherwise, we face years of fighting as the law strives to force people to violate their religious/moral beliefs. Haven't we had enough strife?
I think it's far more likely to happen than you think it would. Especially the scenario where a doc or pharmacist won't even refer a place where they could go. Actually, I'd be willing to bet money that'll give rise to a lawsuit.
Speaking of which, I'd rather sue someone than drive 20 miles for condoms ;)
The whole referral thing is bogus. Can't people use the yellow pages themselves or ask friends for recommendations? Or, as Wesley says, the Internet. If the whole point is that this or that thing is _legal_ in some country, then it's up to the customer to find the service. He can't get in trouble for looking, just as others can't get in trouble for providing the service. Why should any person be required to "refer" someone as to where to find birth control or morning after pills? To me this has always sounded like an attempt to force cooperation as part of an ideology, not like anything really necessary to help the customer/patient.
"Why should any person be required to "refer" someone as to where to find birth control or morning after pills?"
Quite simple - because they're doctors and pharmacists. They are in a position of patient trust and are expected to fully disclose all relevant information.
I actually have a better solution. Why don't we uphold the standards of the position that they voluntarily entered?
No required them to become doctors or pharmacists. If their conscience cannot allow them to fully perform that role, then it's a no-brainer - don't go into that profession.
Should we allow conscientious objectors to join the military then whine about having to kill people?
That doesn't make sense to me.
You're saying that becoming a doctor or a pharmacist means agreeing to dispense or help people to find every legally prescribable drug or treatment out there? How in the world did they agree to that? So, let me get this straight: If in some country it's legal to get your healthy limbs cut off (as discussed in an earlier thread) because this fits your body image, doctors in that country must either perform this operation or put in serious effort to helping a patient find someone who will, even if the doctor himself believes such treatment is horribly immoral and not best for the patient himself? (Remember, people who have moral objections to abortion and birth control would not grant that these things are best for the person in question.) And just by becoming doctors they've signed some invisible contract to do this? How about assisted suicide? That, too?
That's absurd. No one agrees to become a mechanical dispenser of treatments and drugs like that just by becoming a doctor or pharmacist.
And where do condoms come in? Heck, they don't even require a prescription, and you can buy them at a grocery store. They're just another product, like toothpaste. Why should a merchant or pharmacist be required to help someone find them anymore than breath mints?
I was going to agree with Royale, and I still do, but doing some research shows that almost all states already have so-called "conscience clauses" that excuse doctors from performing abortions or in some cases even providing contraception. So I'm not sure what you forced-pregnancy advocates are complaining about here.
"You're saying that becoming a doctor or a pharmacist means agreeing to dispense or help people to find every legally prescribable drug or treatment out there?"
No, of course not.
But they should follow the law and standards of their state board of health. If the state mandates that they refer people to a different provider, then do it. Otherwise, do not go into that profession.
The big salaries of doctors and pharmacists comes at that price. But still, they volunteered for it so I cannot feel sorry if they are placed in such a difficult position.
BTW -
I'm not picking on Catholics, but rather just upholding freely-entered contracts.
I went to Georgetown and there, many students complained that the school's health insurance did not cover birth control pills.
I told them precisely what I'm saying here. If YOU voluntarily enrolled to Georgetown knowing that it's a Catholic school, then boohoo. Or if birth control pills are so important, go to a different school.
Wes, this is interesting in that the reporter who wrote the story is one who called us sometime last year in regard to "conscience clauses." I made much the same point you make about "futile care" being another kind of "conscience clause" but one that was treated separately. At the time, there was coverage of both "futility" and "conscience clauses." Stein eventually said he got it, but didn't intend to write about it.
It would have been a much more interesting study, I think, if they had included feeding tubes and ventilators in their list of "controversial treatments" in the NEJM study.
*That* would be a study worth reading in that I suspect that it would show that a lot of doctors will show the behavior covered in the NEJM article - but what "treatments" they are unwilling to recommend will depend on a number of variables.
mtraven:
"So I'm not sure what you forced-pregnancy advocates are complaining about here."
That's rather narrow, considering that Wes also discussed assisted suicide. Basically, if a doctor or pharmacist has an objection to doing something that he or she thinks is morally wrong, that person should be able to say so, in any case - not just abortion but also in assisted suicide. And as you pointed out, most states already have a clause protecting doctors who have a moral objection to abortion. It's just that it doesn't go far enough.
But Royale, the question is what those state policies ought to be. Even setting aside any question of civil disobedience, it's pretty obvious that there are people out there (including perhaps the authors of the article in question and certainly many of its hypers) who want those state policies to be such that pharmacists and doctors must provide or refer for abortions and contraception. In other words, they'd like to rescind whatever conscience clauses are already in state laws.
Certainly a doctor or pharmacist should take into account a state's laws on this subject and if possible pick a state that allows him the freedom of conscience he's concerned about. But the question is whether he should be allowed that freedom.
My understanding from your earlier posts is that you think it would just be _dreadful_ if state laws were such that some woman might have real trouble finding birth control pills in her town. But why couldn't one say to her something similar to what you said to your Georgetown friends: "Hey, if birth control pills are so important to you, go live in New York"?
In other words, it sounded earlier like you were saying not just that pharmacists and doctors shd. comply with relevant state requirements but that these state requirements should not permit the supposedly horrible situation where a person had to drive 20 miles for birth control pills or put in the time to find a supplier for condoms on the Internet. To which I say, "Boo, hoo."
So I don't think you're going to get a strong enough position such as you want out of simply saying that pharmacists have to follow the standards of their state board of health. If that board allows them not to help people find birth control pills, do you think the policy shd. be changed? If so, _then_ what's your principle? It can't just be that the pharmacist entered into a tacit contract to do so, since apparently in his state he isn't required to do so and didn't enter into any such tacit contract.
What Stephen Drake said is right on the money. These things only tend to look at one side of the coin.
For those who don't know, Drake is with NOT DEAD YET.
Lydia wrote: "the question is what those state policies ought to be"
Fine. Then change it. But that's a very separate question from whether doctors should have the right to have a moral veto over the patients. The latter of which I say, absolutely not.
"Hey, if birth control pills are so important to you, go live in New York"?
I agree. If the state law says so, fine. But again, doctors should NOT have a moral veto over the patients. I don't see why it's so objectionable to have doctors follow the law.
I am probably a bigger proponent of state regulation of medicine that you are.
David wrote:
"This seems highly likely to decrease the pool of doctors you would want attending you when your health was in crisis."
The last time I looked, there wasn't a problem of finding medical school applicants.
If any doctor does not want to follow the law and would rather have a moral veto over his patients, then he should NOT be a doctor in my book.
Royale, I don't quite get where you're coming from. On the one hand, you rejected my characterization of your position as being that doctors should be compelled to help patients find any legal treatment or medication out there. On the other hand, you adamantly state that doctors "shouldn't have a moral veto over patients."
Now, this latter statement would seem to mean that, if a state law as it stands does have a conscience clause, _does_ allow a doctor or pharmacist _not_ to refer a patient for some (otherwise legal) treatment or drug, you would oppose that state law. Wouldn't such a conscience clause about the birth control pill or abortion be "giving the doctor a moral veto over patients"?
But that sounds _exactly_ like what I attributed to you before: You're opposed to conscience clauses for doctors and pharmacists and think they shouldn't be allowed to bring their own notions of wrong and right into play in refusing to help patients find whatever treatment or drug those patients happen to want, so long as it is otherwise legal.
I'm sorry, but that goes far beyond simply saying that doctors and pharmacists have a duty to follow applicable state law. What that means is that applicable state law *must demand* that doctors and pharmacists set aside their moral views if those happen to conflict with a patient's views and must materially cooperate in getting the patient whatever he wants in the way of treatment.
And I repeat what I said before: Those who object to birth control and abortion (not to mention assisted suicide or elective limb removal!) *do not admit* that these are best for the patient. So even if you argue that they, as health professionals, must do what's best for the patient even if they are uncomfortable with it, on their view there will be no conflict there.
My priority is what is best for medicine.
I don't have a problem with conscience clauses so long as they are reasonable.
A Dr objecting to perform an abortion? Fine.
A pharmacist objecting to prescribing birth control pills? Hmmm...borderline.
A Dr or pharmacist refusing to tell the patient where they can get an abortion or birth control pills? Absolutely not.
Why this hierarchy? Because it goes to the patient's trust in the doctor/pharmacist for full disclosure. That is most important here.
Does a state have the right to adopt conscience clauses that conflict with what I would do? Sure. States regulate medicine and have the right to be stupid. Outlaw abortion or allow medicinal marijuana - it IS their right to decide.
Well, I disagree with you, Royale, but I appreciate your clarification.
I just can't understand the drive to require people to "refer." I mean, people are capable of doing their own searching for legal products and services. I do it _all the time_ for various things that local stores don't stock. That's just part of being an adult in the world. If you can't find X or Y at some store or some service, you look around, you ask people, you go on the Internet, look in the phone book. It seems to me that there's something obsessive-compulsive about wanting there to be a requirement in law for these specific products and services (birth control and abortion) making sure that *whatever else happens*, doctors and pharmacists have to cooperate _somehow_ even if this isn't really necessary for the patient. I mean, seriously, do you think patients shouldn't be expected to be competent enough in the world to find this stuff for themselves? Or to find someone with no conscience problem to help them? It isn't like they're going to die in the next five minutes if they do have to drive to a larger town to get birth control pills or an abortion, after looking it up on-line or making a few phone calls. Isn't insisting on this duty of pharmacists to cooperate in some way a little control-freakish?
David Alexander said:"All doctors who adhere to the Hypocratic oath are now barred from being doctors."
That is a very interesting point that we should all ponder.
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