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Physicians’ Perspective
Conscience and Ethics Paternalism versus Patient Autonomy
by Dr. Rick Bayer

Across the US, there is controversy among doctors, ethicists, and patients about the intersection of public service and private conscience in re:to performing legal medical procedures. In Oregon, this contradiction is made apparent when physicians routinely refuse to serve patients’ legal requests to use our Death with Dignity & Medical Marijuana laws.

Recently, in The New England Journal of Medicine (NEJM), Farr Curlin and colleagues published results from a national survey of over 1000 physicians. Doctors were asked about 3 legal clinical scenarios: 1) administering terminal sedation to dying patients; 2) providing abortion for failed contraception; and 3) prescribing birth control to adolescents without parental approval.

Terminal sedation is pain management in terminally ill patients that uses sedation to control pain even if it hastens death. Most medical professionals consider the procedure ethical since the goal is to treat pain and not cause death. Terminal sedation, accepted by both opponents and proponents of Oregon’s Death with Dignity Law, is not so controversial in Oregon.

Most doctors said it is ethical to explain moral objections for denying service (63%); but the doctor should present all options (86%); and if a doctor denies care, he must refer to a doctor who offers the legal service (71%). Male Christian doctors who went to church twice per month or more were least likely to offer services; least likely to give full disclosure about treatment options; and—most importantly—were least likely (56%) to refer to another doctor.

Curlin concludes many doctors do not feel obligated to provide a legal medical service if inconsistent with their religious beliefs. Curlin puts the burden on patients to quiz each doctor about “controversial” medical practices, including reproductive health, pain management, and end of life care.

Many doctors, including me, believe Curlin places too much responsibility on patients to anticipate every health concern. Moreover, in our broken American healthcare system, many have no choice of physician.

In another NEJM article, Alta Charo notes this “privilege” to deny counseling or referral extends to emergency contraception for rape victims, in-vitro fertilization for infertile couples, withdrawal of life support for futile treatment, and therapies developed with fetal tissue or embryonic stem cells. She gives an example that a pediatrician might not recommend chickenpox vaccine because it was developed using tissue from aborted fetuses. She explains that a provider protects only himself with no concern for the suffering of patients.

Charo asks what it means to be a professional? Is it ethical for professionals to exploit positions of authority to pursue religious agendas or win political contests? What duty do healthcare professionals have to provide nondiscriminatory medical care?

Charo argues that when society grants a monopoly to physicians, we become obligated to provide service to all. She says “claiming an unfettered right to personal autonomy while holding monopolistic control over a public good constitutes an abuse of the public trust—all the worse if it is not a personal act but rather, an attempt at cultural conquest.”

Is it ethical for a doctor to deny access to a legal procedure, or fail to explain alternatives; then refuse to refer to another physician who provides the legal medical service? Many feel this is negligent; it potentially harms patients, and deserves investigation.

Oregon doctors must discuss the procedure, alternatives, and risks (PAR) of any treatment. An ethical conscientious objector must refer to a provider who offers the legal procedure. Doctors who harm patients to salve a personal belief must be disciplined as thoroughly as doctors who harm someone due to incompetence.

In the dark ages of medical paternalism, doctors alone decided what was best for patients. Full disclosure about the PAR of treatment is a secular ethical concept based on human rights. Sadly, as Curlin’s data show, paternalism remains—particularly among Christian male doctors fighting culture wars instead of serving patients. This means patients must work to get professionals to conduct a full PAR conference—particularly true if seeking reproductive or end of life care.

If your doctor is being unfair, then change physicians, hire an attorney, and file a complaint with the Oregon Board of Medical Examiners. Refusing to conduct a full PAR conference is unethical and usually illegal. This residual poison of paternalism in medicine is another reason to support single-payer healthcare where patients have both universal care plus complete choice of providers.

Richard “Rick” Bayer, MD, FACP is board-certified in internal medicine, a Fellow in the American College of Physicians (FACP), practiced, and lives in Oregon.


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