Saturday, February 10, 2007

Faith, Physicians, and Ethical Practice

I was alerted yesterday to a recent study on physician ethics by this report on NPR’s Talk of the Nation. Dr. Farr Curlin, assistant professor, Section of General Internal Medicine and the MacLean Center for Clinical Medical Ethics at The University of Chicago, was interviewed regarding the article, “Religion, Conscience, and Controversial Clinical Practices,” of which he is one of the authors. You can find the article in the February 8 edition of The New England Journal of Medicine.

Ethical norms and practices of physicians is, of course, an important subject. There is ongoing debate about balancing the principles of patient autonomy (which at its worst I often characterize as “Whatever Lola wants, Lola gets”) and of the moral integrity and autonomy of physicians. As the authors note,

Recent controversies regarding physicians and pharmacists who refuse to prescribe or dispense emergency and other contraceptives have sparked a debate about conscientious objection in health care.1,2,3,4,5 On the one hand, most people believe that health professionals should not have to engage in medical practices about which they have moral qualms. On the other hand, most people also believe that patients should have access to legal treatments, even in situations in which their physicians are troubled about the moral implications of those treatments.6 Such situations raise a number of questions about the balance of rights and obligations within the doctor–patient relationship. Is it ethical for physicians to describe their objections to patients? Should physicians have the right to refuse to discuss, provide, or refer patients for medical interventions to which they have moral objections?

Physicians in the study were asked to focus on three questions:

The primary criterion variables were physicians' responses to 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? Does the physician have an obligation to present all possible options to the patient, including information about obtaining the requested procedure? Does the physician have an obligation to refer the patient to someone who does not object to the requested procedure?" Response categories were yes, no, and undecided.

We also assessed physicians' intrinsic religiosity and religious affiliations. Intrinsic religiosity — the extent to which a person embraces his or her religion as the "master motive" that guides and gives meaning to his or her life12 — was measured on the basis of agreement or disagreement with two statements: "I try hard to carry my religious beliefs over into all my other dealings in life" and "My whole approach to life is based on my religion…." Intrinsic religiosity was categorized as being low if physicians disagreed with both statements, moderate if they agreed with one but not the other, and high if they agreed with both.

Physicians were also asked about religious affiliation and about frequency of attendance at worship.


To determine whether physicians' judgments about their ethical obligations are associated with their views on controversial clinical practices, we asked the survey respondents whether they have a religious or moral objection to terminal sedation (administering sedation that leads to unconsciousness in dying patients), abortion for failed contraception, and the prescription of birth control to adolescents without parental approval.

These measures provided some of the results of greatest interest to me. For example, a majority of respondents described their religiosity as either “High” (36%) or “Moderate” (27%). Only 10% stated that they never attended worship, with the largest segment attending “Twice a month or more” (46%). Again, only 10% claimed no religious affiliation (a category that included identifications as atheist, agnostic, or none). While that’s not different from my experience of physicians, it suggests physicians are at least as religious, both in self-report of religiosity and in regular worship, as the general population.

Of greater interest as a chaplain and chair of an ethics committee are the responses to the primary questions. A majority felt it would be ethical for a physician to describe in detail objections to a procedure (63%). Larger majorities felt an obligation to inform a patient of all available treatment options, including those to which the physician objects (86%), and to refer a patient to another physician who did not share those objections (71%). These numbers suggest a strong commitment to fully informing patients.

At the same time,

Physicians who were more religious (as measured by either their attendance at religious services or their intrinsic religiosity) were more likely to report that doctors may describe their objections to patients, and they were less likely to report that physicians must present all options and refer patients to someone who does not object to the requested procedure. As compared with those with no religious affiliation, Catholics and Protestants were more likely to report that physicians may describe their religious or moral objections and less likely to report that physicians are obligated to refer patients to someone who does not object to the requested procedure.

In one sense, this is not a surprise. Issues were suggested in the study to which physicians might object, and on which many religious communities have taken positions. Those positions would certainly suggest moral norms for responding to those issues. With physicians in this study as religious as the reported, it doesn’t surprise me that those who would not inform or refer for those positions to which they object would also be among those who are religious.

At the same time, it would certainly make a difference to a patient to know where the doctor stood. The patient may be pleased, or may want to seek another physician; but the patient would not be likely to consider it irrelevant. Unfortunately, the question would be unlikely to arise until the issue was acute. In that case the accuracy and timeliness of information would be highlighted. In addition, among the citations in this article are several articles that suggest the state licensing of physicians, and thus state establishment of a de facto “monopoly,” creates a greater responsibility for public service and public utility that would argue against physicians’ professional autonomy. And if the physicians here are in the minority, they would still represent significant numbers of physicians.

The authors conclude,

the results of our study suggest that when patients request morally controversial clinical interventions, male physicians and those who are religious will be most likely to express personal objections and least likely to disclose information about the interventions or to refer patients to more accommodating providers. Ongoing debates about conscientious objections in medicine should take account of the complex relationships among sex, religious commitments, and physicians' approaches to morally controversial clinical practices. In the meantime, physicians and patients might engage in a respectful dialogue to anticipate areas of moral disagreement and to negotiate acceptable accommodations before crises develop.

I would step beyond the suggestion of “might engage” to argue they “must engage.” The physicians who care for us are every bit as human as we are, and every bit as prone to moral anxiety and ambiguity. Perhaps it seems unfortunate that we as patients might need to take initiative to clarify with physicians where they would stand on moral issues and controversial procedures. At the same time, both patients and physicians are responsible for the quality of doctor-patient relationships, and for the honesty and clarity that contribute to them. We want them to be clear with us – whichever side of that exchange we are on.

No comments: