Some Doctors Still Think They Know Best—They Are Wrong

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The Washington Post is reporting the results of a physician survey published in the New England Journal of Medicine that finds that a small, but significant portion of doctors "believe that they have the right not to tell patients about treatments that they object to on moral or religious grounds and to refuse to refer patients elsewhere for the care."

The survey asked them about three controversial practices: (1) sedating dying patients to the point of unconsciousess; (2) prescribing birth control to teenagers without parental notification; and (3) performing abortions after failed contraception. Of those who responded 17 percent objected to terminal sedation, 42 percent object to providing birth control to teens without parental consent, and 52 percent objected to abortion after failed contraception.

The good news is that 86 percent agreed that they had an obligation to present all possible medical options to their patients. Yet 8 percent do not believe that they must tell patients about legal medical options to which they object. In addition, 18 percent felt no duty to refer patients to other doctors who do not have moral or religious objections to these controversial practices.

The Post reports:

R. Alta Charo, a bioethicist at the University of Wisconsin at Madison, said the results were disturbing, particularly the belief by a significant proportion of doctors that they do not have an obligation to inform patients about all options.

"How are patients supposed to make choices when they don't even know the range of choices that they have?" Charo asked. "Failure to inform completely disables a patient. It makes it impossible for them to even know what to ask or whom to ask or where to go to ask."

But Al Weir, director of Campus and Community Ministries for the Christian Medical & Dental Associations, defended doctors' rights to adhere to their personal beliefs.

"The doctor has the right to follow their own moral compass and their own moral integrity," Weir said.

The question here is, Whose values are to triumph in the therapeutic encounter? In the bad old days of a couple of generations ago, the doctors' values generally did. But in a significant moral advance, we have come to recognize that respect for the autonomy of patients is a (if not the) primary value in medical care.

It would be morally odious to force physicians to participate in treatments that they believe are evil. Thus, we do not require that Catholic hospitals offer contraception or abortions.

However, Oxford University bioethicist Julian Savulescu argues that "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."

I have considerable sympathy with Savulescu's argument. Nevertheless, I think that if a doctor is willing to tell his or her patients about all options and refer them to other physicians who are willing to offer the requested treatment, then he or she has fulfilled his or her moral duty. On the other hand, keeping information about patient options secret is medical malpractice and should be treated as such.

Whole Post article here. Whole NEJM article here.

My Reason colleagues weigh in on conscience clauses in medical care here and here.

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  1. I suppose Wal-Mart has to tell its customers what they sell at Target to be ethical, as well.

  2. yeah, totally the same thing and everything.

  3. I don’t see an easy answer here.

    If you believe something is morally wrong – such as abortion – isn’t telling somebody about contributing to the wrong? Doesn’t it make you a collaborator?

    This seems to me like Augustine’s refusal to lie to save the life of a child.

    OTOH, the patient-doctor relationship is somewhat contractual, requiring the doctor to fully disclose, to the limits of his ability and the patient’s comprehension, what options are available and the risks and benefits of those options.

    As I said, no easy answer.

  4. “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.”

    What nonsense. Willingness to perform an abortion or euthanasia has nothing to do with a doctor’s ability to treat cancer, set a broken arm or remove bullets. Yeah, let’s get rid of people who perform life-saving operations because they don’t entirely agree with our dogma.

    And it made me a little happy that more than half the doctors were personally against abortion. Good.

  5. I have no problem with a doctor who declines, for whatever reason, to offer a treatment which he does not approve of, or which he does not think will be effective or proper. However, he ought to be willing to tell the patient, “I think you would be happier with Doctor _______; I will give you a referral.”

  6. The basic question here is: Is the doctor’s allegiance to their own moral conscience or to their patient’s?

    I know my answer.

  7. Uh…… abortion after failed contraception. Isn’t that, like, most abortions?

  8. I realize that the concept of public service isn’t particularly honored ’round these parts, but when you choose to become a physician, like when you choose to become a Marine, you are agreeing to certain restrictions on your autonomy, restrictions that exist for the purpose of furthering important public policy objectives.

    It is important that the Marines be an apolitical force that submits to the chain of command, and this often involves individual Marines setting their own preferences aside.

    Similarly, it is important for the medical profession to be a sphere in which doctors prioritize their patients’ autonomy over their own preferences, however deeply held.

  9. John,

    Is refusing a referral simply the doctor exercising his conscience, or imposing it on the patient?

  10. “Uh…… abortion after failed contraception. Isn’t that, like, most abortions?”

    Not necessarily. Israel, for example, has the world’s highest rate of virgin birth.

  11. Why would a doctor have to inform his patient about abortion? Is there really anybody who doesn’t know about abortion already?

    This whole issue is just stupid. I have never been to a doctor who presented me with a set of options. 90% of the time, they just give you a prescription for the drug you want, and 10% of the time they present you with one option. That’s the way the real world works.

  12. By the same token, maybe the abortion doctor has a moral duty to inform her patient about the moral considerations and potential mental health implications that the patient might not have thought of on her own.

    In the case of late term abortions, preferably with photos.

    Public policy can be a 2 way street, joey bee.

  13. 1. You shouldn’t need government permission to practice medicine. (Come on libertarians, this is basic dogma).
    2. Given #1, Singleton is right – WalMart isn’t expected to tell customers about Target. Go to the doctor you want. Some will advertise “We tell you all the options”. If they fail to do so, you have a contract claim.
    3. Licensing a profession and then expecting them to act “ethically” is retarded. (My CA bar number is 100017)

  14. David,

    The doctor can only impose their conscience on this patient, i.e. keep them from recieving their desired “treatment”, if the patient is forced into some conctractual exclusivity with this particular doctor.

    The patient is free to shop elsewhere and the doctor would violate their moral conscience in facilitating “treatment” they consider unethical.

    Presumably, in a diversified and dynamic medical market, this information would be quite known. Few patients looking for these “treatments” would go to doctors knowlingly opposed to the procedure; doctors are very specialized. Likewise, general insurance plans will have doctors able and willing to give the broadest range of treatments to satisfy their customer base.

    Lastly, most referrals aren’t given by doctors, at least initially. They’re given by friends, business plans, insurance companies and the like, matching specific treatments to specific patient needs prior to the office visit.

    This dilemma is easily solvable without forcing a doctor to do something they are morally opposed to.

  15. Dave W.,

    What’s an “abortion doctor?” I never see the term “listening to your heart with a stethescope doctor” or “write a prescription for Flomax doctor.”

    Anyway your analogy is a bit off. The equivalent wouldn’t be informing the patient who requests an abortion of the alleged consequences. The flip side would be for a doctor who is willing to perform an abortion but who doesn’t believe in pre-natal care (hey, man, you started this thought experiment) to tell his patient that there are doctors our there who provide pre-natal care.

  16. Similarly, it is important for the medical profession to be a sphere in which doctors prioritize their patients’ autonomy over their own preferences, however deeply held.

    So, tying this back to an earlier thread, all doctors would be forced to amputate Susan Smith’s healthy legs?

  17. What’s an “abortion doctor?”

    A doctor who presents the range of medical options to her patients in such a way that abortion is effectively encouraged as the preferred alternative.

  18. Joe, I respect you and all, but “…when you choose to become a physician, like when you choose to become a Marine, you are agreeing to certain restrictions on your autonomy, restrictions that exist for the purpose of furthering important public policy objectives.” is truly apples and oranges. You are apparently unaware of the differences bewteen Hippocratic Oath and the swearing-in ceremony of the USMC where new recruits become the literal property of the US gov’t. Or are you just playing stupid to score rhetorical points?

  19. The doctor can only impose their conscience on this patient, i.e. keep them from recieving their desired “treatment”, if the patient is forced into some conctractual exclusivity with this particular doctor.

    The patient is free to shop elsewhere and the doctor would violate their moral conscience in facilitating “treatment” they consider unethical.

    But if the doctor was withholding treatment options, how would the patient know? I’m not sure I want to “shop around” every time I have a health problem to make sure all possible treatments have been considered.

    Joe is basically correct here. Physicians have a duty to the public to put their well-being of their patients ahead of their own moral sensibilities.

  20. Ideally, doctor’s wouldn’t need liscences and patient choice would fix this. Since doctors enjoy a government enforced cartel, I’m OK with calling it malpractice if a doctor doesn’t mention all the options or at least refer a patient to someone who will. Some doctors are even worse, they’ll neglect to mention side effects when the patients ask, because they want the patient to choose a drug.

  21. I am absolutely fine with doctors withholding information on moral grounds, providing they make their policy on this matter quite clear to prospective patients. This prospective patient would then make the informed decision to consult with a different doctor.

  22. Anvilwyrm,

    “So, tying this back to an earlier thread, all doctors would be forced to amputate Susan Smith’s healthy legs?”

    Good question. How about I replace “autonomy” with “interests,” and stipulate that autonomy should be presumed to be the most important interest, to be over-ridden only in extreme circumstances. Further, deciding whether these circumstances apply needs to done at a higher level than the individual doctor.

    Lurker Jack,

    I don’t think you know what the word “literal” means. Marines are not the property of the government – they are agents of the government who are bound to follow its direction, just as physicians are agents of the medical profession.

  23. I don’t see an easy answer here.

    I do. Don’t become a doctor, or don’t go into a field where you’re going to be faced to make a moral decision like this. Don’t be a pharmacist if you have a moral opposition to prescribing drugs.

    Dave W.,

    What’s an “abortion doctor?”

    Don’t waste your time. It’s pretty clear “Dave W.” has an agenda. There’s no point in discussing this with him.

  24. “42 percent object to providing birth control to teens without parental consent”

    How does this issue even come up without the teen requesting the option in the first place and therefore not a case of the doctor restricting the knowledge of alternative options?

    The definition of what constitutes a teen need to be restrictively defined to avoid the appearance that the question was not asked to elicit an answer that fits some preconceived notion; the rights and responsibilities of a 13 year old and not the same as a nineteen year old. While this may seem obvious, those that would nullify the 2nd amendment routinely define twenty year old men as children.

  25. I don’t think it’s imposing an odious burden to remind people that they ultimately bear responsibility for their bodies and should always seek more information about all of the options available to them.

    Given the easy accessibility of a lot of information on general medical options and procedures that is available to the American public, people should be looking up their options on their own so they are better informed when they go to the doctor.

    I think asking people to take responsibility for their own bodies is far more preferable than making doctors slaves to the state.

  26. The more enlightening scenario to discuss is something like Emergency Contraction (EC or Plan B) instead of abortion.

    It’s a scenario that adds a time sensitive variability in one’s response as to whether a doctor should or should not follow their moral compass or act in the patient’s wishes. In some cases, the refusal to write the scrip for EC can in fact totally deny that person effective access to it (based on geography or the fact that it’s Friday midnight).

  27. The saying “courage of your convictions” comes to mind. These doctors don’t risk anything by following their moral compass, their patients do. Limiting a patient’s treatment options through omission is selfish at best. These self absorbed jackasses need to grow up.

    Yeah, it’s really moral to make other provide the courage for your own convitions.

  28. When one is in a time-sensitive situation (say, having cancer, being very sick, in the throes of a heart attack) one CAN’T go around checking up on all the medical information out there.

    Also, if a physician refuses to tell me about a treatment and I end up permanently worse off (or dead) because of that, a fat lot of good it’s going to do me if I sue him. I’d rather insist that he be mandated to tell me all the info beforehand. And I think most Americans would prefer that as well. You may disagree, but you’re going against the sense of common experience.

    What libertarians never seem to understand is that a) information is never free and b) time is not free. Over and over again I’ve seen this–libertarians acting as if information is immediately available and doesn’t require any time or effort to find it. Grow up–it does.

  29. My eye doctor told me that medical MJ is a hoax and that, GET THIS, smoking pot does NOT help glaucoma.

    Shall I sue him for malpractice?

    Nah, he’s a good doctor and very conscientious. He has given me the best vision I’ve had since I began wearing glasses.

    Okay, I don’t have glaucoma or cancer, so maybe it doesn’t count.

  30. Grumpy,

    Point taken but you’re going to be in the same situation that you describe anyway because there are some physicians that are more with it than others.

    A doctor that doesn’t tell you about all the treatment options is not all that rare because frankly, she may not know about all of them. Laws mandating full disclosure won’t help that.

    Hell, I have a friend that died because the Navy doctors couldn’t find a cancerous tumor the size of a baseball. Ray, go home and take some laxatives, it’s a blockage of some kind.

    Ideally, it pays to do your homework and make your choices up front. I already know if I get prostate cancer I’m driving straight to Loma Linda University.

  31. yeah, it’s really moral to make other provide the courage for your own convitions.

    That’s a good point which is why you need to take as hard a look at your doctor as you would your mechanic or the plumber. Doctors get a bye simply because they’re doctors, which I think is one of Ron’s significant points.

    You better ask up front if the guy’s a Jehovah Witness and is going to refuse to give you a blood transfusion while you lie bleeding to death after flying through the windshield because you refused to obey the law that says you must wear seatbelts.

  32. “…you need to take as hard a look at your doctor…”

    I agree. Although it can be difficult to change doctors with some insurance companies. When I’ve wanted to do so I just tell the phonedroid I’ve moved.

    I also ask them to explain what they’re doing- whether they’re writing a prescription or sticking a finger in my nether regions. I learned my lesson when I was butchered by an unexperienced doctor when she removed a mole on my back- of course I tell the ladies it’s a bullet wound.

  33. In an emergency situation (heart attack was mentioned above) the doctor is going to do what they think is best. I am pretty much okay with this.

    In a less time critical situation doctors should be sharing all reasonable options with the patient. I hesitate to say ALL treatment options, as this could be very time consuming and confusing. I would draw the line around the 99% line, i.e. what are the options that are cumulatively add up to 99% of the treatments used in similar cases.

    I am also pretty okay with the doctor specifying which things on the list they are unable or unwilling to do. I really don’t think I would want a doctor performing a procedure he didn’t believe in. Odds are, he isn’t that good at it.

  34. Stupendous, always tell them it’s a bullet wound. They swoon.

    I learned my lesson after a routine kidney scan almost killed me. Turned out I am deathly allergic to the iodine they inject you with. Nobody asked me or even brought it up. Not the doctor or the techs.

    I’m a pit bull about it now. Any iodine in that stuff? You sure? I’m deathly allergic, any iodine in that stuff? Iodine in particular, but other things as well.

  35. I’m thinking that any treatment a doctor finds immoral can be described as harmful to the mental health of the patient, or family member, or whatever.

    If the gubment is going to micromanage diagnoses and treatment, then why have doctors at all? Presumably most doctors migrate to a specialty that offers treatments they find moral.

  36. Shall I sue him for malpractice?

    Nah

    If it turns out that MJ prevents glaucoma, and you end up getting glaucoma, then I say go for it. i certainly don’t want my insurance company picking up the tab on that, if it turns out we have the same insurer.

    Has anybody compared the glaucoma rates in Amsterdam to those in its sister city in the Bible Belt (Atlanta? Orlando?)?

  37. …sedating dying patients to the point of unconsciousness…

    Oh come on! If we aren’t going allow euthanasia in this country, then this should be a no-brainer. What kind of sick, sadistic, fuck would deny, for example, a terminal cancer patient relief from their agony in their final moments?

    Oh wait, we’re talking Christians here, aren’t we? That explains it.

    “The doctor has the right to follow their own moral compass and their own moral integrity,” Weir said.

    Your “moral compass” and “moral integrity” end where my health begins, Doc. If you don’t have the cahones to treat me, then at least refer me to who can. If you won’t do that, then fuck you AND your the deity you mindlessly worship.

    You took an oath, doctor. Do your gorram job, or I’ll take my business who will and who my insurance plan covers.

    Thus, we do not require that Catholic hospitals offer contraception or abortions.

    However, most of us can figure that out going in. As an atheist, I know to steer clear of blatantly religious hospitals. However, how am I supposed to know if my doctor isn’t a raving fundie who will refuse to perform certain treatments? Do I have to ask? Should we require to publish a statement of their bioethical principals?

    I’m with Savulescu. If you want to preach religious dogma, go to the seminary, not medical school.

  38. EDIT: …If we aren’t going to allow euthanasia…

    …I’ll take my business to one who will…

  39. I learned my lesson after a routine kidney scan almost killed me. Turned out I am deathly allergic to the iodine they inject you with. Nobody asked me or even brought it up. Not the doctor or the techs.

    Odd. Every MRI I’ve ever taken required me to sign a waiver. Some of the reactions to that contrast dye are quite alarming.

  40. A girlfriend of mine, at age 31, was diagnosed with breast cancer. She was also four months pregnant.

    Among the medical options presented to her was an abortion and immediate chemotherapy. She could not undergo chemo so long as she was pregnant.

    Would her doctor have been acting immorally if he had withheld telling her of this option since it necessarily involved abortion?

  41. Would her doctor have been acting immorally if he had withheld telling her of this option since it necessarily involved abortion?

    Not only should have advised her of the immediate abortion option, but they should also advised her of the viability point, and the likely consequences of waiting until viability b4 proceding with chemo.

    They should have been required to inform her of both these options. Not just one.

    They should also have informed her that some breast cancer patients skip chemo all together, fetus or no fetus:

    http://www.msnbc.msn.com/id/13284123/

    They should have been required to tell her of at least these 3 options, in a value neutral way, so that she could excercise her choice in an informed manner.

  42. Forget sedation to unconsciousness. Where’s the doctor who will administer ecstasy to me on my deathbed?

  43. Pangolin nails it right on the head:

    Why would a doctor have to inform his patient about abortion? Is there really anybody who doesn’t know about abortion already?

    Unfortunately, this is one of those issues (funding stem cell research is another) where many here are more interested in opposing Christians than maximizing liberty.

  44. After suffering the last 7 years with debilitating cluster headaches,I have found most physicians are useless when it comes to treating pain.To evem mention that you are in pain seems to set them in a tizzy.You are obviously an addict or druggie.Their immediate response when painkillers are requested is “You’ll become addicted!”The pain of these headaches are enough to drive one to thoughts of suicide.All I want is some relief.There also tends to be a lot of arrogance among physicians.They have one pet remedy for a given ailment,and if it doesn’t work,they are unwilling to try anything different.I’ve tried every migraine remedy available with no relief yet.That makes doctor think I’m lying just to get narcotics,that all those vaunted new migraine drugs just have to work,even though the literature included says they are not effective for certain types of headaches.I do wonder where the compassion has gone.

  45. Oxford University bioethicist Julian Savulescu argues that “a doctor’s conscience has little place in the delivery of modern medical care”

    Let me guess — this guy runs an HMO, right?

  46. Unfortunately, this is one of those issues (funding stem cell research is another) where many here are more interested in opposing Christians than maximizing liberty.

    Seeing that religion, particularly Christianity, is tied for first place with government as mankind’s primary oppressor, those of us who wish to maximize liberty should be very interested in opposing Christians.

  47. Wal-Mart doesn’t perform a vital public service. Wal-Mart is not entrusted with protecting human lives. That’s actually a very weak analogy.

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