Tuesday, February 6, 2007

Just following orders, sir!

NEJM 356;6, Feb 8, 2007 pp. 593-600.

The latest issue of the New England Journal (356;6. Feb. 8, 2007) has an interesting article: "Religion, Conscience, and Controversial Clinical Practices" in which the investigators sought to determine the degree to which a physician’s personal beliefs impact the patient’s autonomy. They asked the following three questions:

  • If a patient requests a legal medical procedure, but the patient’s physician objects to the procedure for religious or moral reasons, would it be ethical for the physician to plainly describe to the patient why he or she objects to the requested procedure? Answer: 63% said yes.

  • Does the physician have an obligation to present all possible options to the patient, including information about obtaining the requested procedure? Answer: 86% yes

  • Does the physician have an obligation to refer the patient to someone who does not object to the requested procedure? Answer: 71% yes

    They found that white males who were religious were the most likely to object and disagree with the obligation to inform patients where to obtain such a desired procedure. This is a fascinating topic for me, a practicing Catholic white male physician, and I’ve come to realize that I’m even further removed from my colleagues. For example, while the investigators’ specific question about birth control had to do with prescribing to minors without parental consent, I do not prescribe birth control for any reason. My office staff is trained to tell all new female patients of reproductive age that I don’t do this.

    I honestly don’t know exactly where my boundaries lie, but they have to do with the question of whether life is being destroyed. For example, I absolutely will not be complicit in any way with one of my patients who wants an abortion. If asked, I will certainly outline all the available options, but I will not actively assist her with finding someone who will perform an abortion. I recognize the sanctity of life from moment of conception to the point of natural death, which means euthanasia is out, as well.

    On the other hand, I have given Viagra to people who are engaging in fornication. I have referred patients to be mutilated by means of vasectomy or tubal ligation for the sole purpose of infertility. Does it keep me awake at night sometimes wondering if my prescription for Viagra allowed a man to have an extramarital affair? Yes, but I justify it somehow by concluding that I’m not destroying a human life and that my personal responsibility for others’ lives has to stop somewhere. For that matter, I treat patients who are actively homosexual, actively promiscuous, or have other worldviews with which I disagree. I don’t claim to have all the answers, but just as I have the right to discharge a patient from my practice for noncompliance with my recommendations, I have the right to practice medicine the best way I know how.

    If I’m asked, I will tell women why I don’t believe in prescribing birth control. To my knowledge I can only think of one woman who found my personal stance unacceptable and went somewhere else.

    I noticed that the lowest percentage of responders in this study were OB/GYNs (7%) – the same specialty that deals most often with issues like abortion, birth control, fertility, etc. Is that a coincidence? My position is that my job is to inform patients fully on the options and consequences of their decision making, but I do not have to take an active part in their doing something to which I am morally opposed. My patient’s right to self-determination is not removed by my refusing to participate in these actions. This opinion places me at odds with Savulescu who wrote, "a doctor’s conscience has little place in the delivery of modern medical care" and that "if people are not prepared to offer legally permitted, efficient and beneficial care to a patient because it conflicts with their values, they should not be doctors." ( Conscientious objection in medicine. BMJ 2006;332:294-7). Come to think of it, Mengele was very efficient...

    After all, if something’s legal it must be moral.