"Values Play Into Treatment Recommendations, Study Finds"

Read the full article by Rob Stein in The Washington Post, February 8, 2007.

Stein reports on a study lead by Farr A. Curlin, a bioethicist at the University of Chicago, published in today's issue of the New England Journal of Medicine.

Read the full text of:
"Religion, Conscience, and Controversial Clinical Practices"
Farr A. Curlin, M.D., Ryan E. Lawrence, M.Div., Marshall H. Chin, M.D., M.P.H., and John D. Lantos, M.D.

The study focused on "physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for religious or moral reasons. These procedures included administering terminal sedation in dying patients, providing abortion for failed contraception, and prescribing birth control to adolescents without parental approval." The authors of the study state:

On the basis of our results, we estimate that most physicians believe that it is ethically permissible for doctors to explain their moral objections to patients (63%). Most also believe that physicians are obligated to present all options (86%) and to refer the patient to another clinician who does not object to the requested procedure (71%).

Comment: This study focuses importantly on the obligations of physicians to provide information to their patients, and thus fits within the focus of "Knowledge for Development".

* "Present all options": it seems to me that a physician has not only a moral but a legal obligation to inform a patient of his diagnosis, alternative treatment options, the prognosis (including alternative scenarios and their likelihood), and their costs.

* "Refer patients to another physician who does not object to the requested procedure": This seems a complicated issue to me. Certainly if the physician knows that others will perform the procedure, he should convey that information to the patient. Indeed, this is similar to the ethical responsibility of the physician with respect to informing the patient about "second opinion" options. At the other extreme, the physician does not have a responsibility to have encyclopedic knowledge of physicians and their practices. But what about situations, such as where a patient is not likely to have geographic access to an affordable source for a given procedure which they might prefer?

How about "explaining moral objections"? Moral objections may have several different bases:

* Professional judgment of efficacy: physicians differ in their interpretation of evidence, and a physcian may feel that a legally available treatment has a balance of risk and potential benefit such that it is not ethical. Assuming that the physician believes that a patient can comprehend moral objections to a treatment based on such an assessment, of course the physician has the obligation to inform the patient. But does a physician have a responsibility to tell a patient that a treatment is legally available in Mexico or Russia that is not approved in the United States, and that the physician believes to be quackery?

* Philosophical objections: For example, a physician may feel that a patient has not adequately prepared his family or his estate, and that it would be morally incorrect to fully sedate that terminal patient (and reduce lucidity) before adequate preparations had been made. In such a circumstance, it would seem to me that the physician has an obligation to inform the patient or the person acting in the patient's interests of the options.

= Religious objections: The obvious concern of the investigators is the situation in which a physician's religious beliefs are such that he/she believes that a legal and efficacious medical procedure is not morally acceptable. It seems to me that a physician has the right, but not the obligation to tell a patient that he/she has religious objections to a course of treatment that he/she is describing. If, however, the physician is refusing to prescribe or perform the treatment it seems to me there would be an obligation to explain that the refusal is due to the physicians religious beliefs. On the other hand, it does not seem to me that a physician has the obligation to explain to the patient the religious reasons for that objection. Indeed, I would feel that a physician has an obligation not to proselytize patients in the consulting room.

More generally, it seems to me that the argument is much stronger that the physician has a moral obligation to inform the patient of the options than that there is an obligation to prescribe or perform the therapy. I would find it hard to accept on any basis that a physician has a moral obligation to keep a patient in ignorance of professionally accepted, legal medical options that the patient might reasonably choose.

Indeed there may be (or perhaps should be) a legal obligation on the physician to provide such information to the extent that it can be absorbed. Physicians are licensed by the government, and with that licensing should come responsibilities to provide full and accurate information to patients. Perhaps individuals who have religious objections to fully providing medical information should not be licensed, and indeed should not take up space in medical schools that could be used by people who would fully disclose the medical situation to their future patients.

In the United States, there is a deep philosophical commitment to freedom of religion. We tend less and less to legislate morality, focusing instead on protecting the public interest. Even a majority view, much less a minority view, may be left to individual judgment rather than imposed by law. So, in this society, a doctor should provide the information to a patient to allow that patient to make his own moral judgments. Perhaps the situation is different in other cultures or in theocratic states, but here a physician should not impose his/her own religiously-based moral judgment on a patient, who may be of a different religion or who may simply decide to behave immorally, by keeping that patient in ignorance.

I do believe that morality trumps legal responsibility. For example, doctors in Nazi Germany should have refused on moral grounds to do immoral things that were legally required of them by such a government. However, there are moral responsibilities for physicians to inform their patients and to respect the patients right to free choice.