A physician’s obligation

I’ve written about the corrosive effect that religion can have on medical care when it is allowed to become too pervasive. One example where the intersection of religion and medicine concerns me is when various religious doctors insist on very dubious evidence that religiosity is good for a patient’s health and that physicians should therefore take a “spiritual history” of all of their patients, with one even going so far as to claim that “excluding God from a consultation should be grounds for malpractice.” I’ve also critically discussed studies that purport to show various benefits of prayer, particularly in cancer patients. It figures that, while I was away in Phoenix, there would be a large study published in the New England Journal of Medicine on a topic that should be of great interest to many surgeons: What is the obligation of a physician to inform patients of medical options that the physician personally finds morally objectionable? This is the sort of question that comes into play more and more often; examples include emergency contraception (the “morning after” pill, which some pharmacists have refused to dispense), termination of nutrition and hydration (as in the Terri Schiavo case), abortion, physician-assisted suicide, and terminal sedation in the case of patient dying of an incurable cancer. These questions are truly difficult and passionately argued.

Basically, a group from the University of Chicago surveyed 2,000 practicing physicians on their attitudes regarding their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for religious or moral reasons.

The conclusions of the study from the abstract:

Results: A total of 1144 of 1820 physicians (63%) responded to our survey. 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%). Physicians who were male, those who were religious, and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds (multivariate odds ratios, 0.3 to 0.5).

Conclusions: Many physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures. Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests.

If we look at the study in a little more detail, a number of interesting additional observations come out, besides the conclusion that 14% of physicians do not feel obligated even to disclose legal and viable medical options that they consider morally objectionable. For one thing, the true number reported was 8%, with 6% undecided over whether the physician has an obligation to present all possible options to the patient. That’s a little better. On the other hand, only 71% stated that a physician who has a moral objection to a course of treatment that a patient desires to request is obligated to refer the patient to a physician who does not share that objection. Not surprisingly, the number of physicians who believed that physicians are obligated to disclose all options was inversely related to the religiosity of the physician. Of those scoring high on the intrinsic religiosity scale, 19% did not think that physicians are obligated to disclose all possible treatment options while among those scoring low on the intrinsic religiosity scale, only 8% held this opinion; for the question about whether physicians are obligated to refer the patient, only 56% of highly religious physicians agreed that physicians are obligated to refer the patient, while 82% of physicians of low religiosity agreed. A similar inverse relation was found for these variables when compared with the frequency of attendance by the answering physicians at religious services. Not surprisingly, male physicians were also the least likely to disclose or refer if they had a moral objection. Or, as Dr. Bernstein put it:

Although, the study revealed only what physicians said about the issue and not whether they actually practiced what they said. Nevertheless “if the physician’s ideas translate into their practices, the 14% of patients–more than 40 million Americans–may be cared for by physicians who do not feel they are obligated to disclose medically available information they consider objectionable. In addition, 29% of patients–nearly 100 million Americans–may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments.”

Or, from my perspective, what this study reveals is that as many as 14% of physicians do not feel ethically obligated to disclose all possible treatment options if any of those options conflict with their personal religious or moral beliefs, and 29% do not feel obligated to refer to another physician. Virtually all these beliefs are based on the physician’s religion, and here’s where the conflict comes in. What if a patient does not share the physician’s religion? The issue of birth control perfectly encapsulates this problem, if you imagine a devoutly Catholic physician being approached by a patient who is not Catholic and does not subscribe to the Catholic Church’s teachings wanting birth control or emergency contraception? Should a Catholic physician or a fundamentalist Christian physician be given carte blanche not to inform a patient about a legal procedure simply because his or her religious beliefs consider it a sin, particularly when many religions do not?

Another point to be considered is that 63% of physicians consider it ethical to “plainly describe to the patent why he or she objects to the requested procedure.” On this issue, I’m a bit more ambivalent. On the one hand, how can a physician not inform a patient of his or her moral qualms over a course of treatment? On the other hand, as much as we physicians bemoan our diminished status and authority, there is still a deep wellspring of respect for us among most people, and our opinions still matter. Our informing patients of our moral qualms about procedures that, while perhaps controversial, are still considered legal and, by a significant proportion of the population, morally acceptable risks excessive paternalism. Even after having been in practice as an attending for nearly eight years and having been treating patients for 19 years, it still amazes me how much deference patients will show to our opinions as physicians. We physicians have a lot of influence with our patients; in fact, we have an almost scary amount of power. Even without active intent, we can influence patients through even attitudes and body language when discussing various treatment options We tend to forget that. And the more religious a physician is, this study suggests, the more likely he or she is to withhold form the patient the most important ingredient to good shared decision-making with regards to health care: information. This is an effect of religion that is every bit as pernicious as insisting on a “spiritual history” for a patient who may not need or want one. Telling a patient that your personal religious beliefs are such that you cannot in good conscience recommend or participate in a course of treatment is one thing, but not even informing the patient of the option because of your religious beliefs is paternalistic and robs the patient of autonomy.

What we as physicians have to remember here is that we exist to serve the patient. Although we are morally obligated to provide the best care and to provide for our patients the best medical advice that we know how, we have to be willing to acknowledge and accept that our our religious beliefs may not be our patients’ beliefs. When our personal religious or moral beliefs come in conflict with those of our patients, that cannot serve as a reason not to inform the patient of all the medically acceptable options that exist. Although we are morally obligated to provide the best care and to provide for our patients the best medical advice that we know how, we have to acknowledge that our religious beliefs should not be used to prevent patients from pursuing courses of treatment that we may find morally objectionable. Physicians who cannot do that should either not be in areas of medicine where they are likely to encounter such conflicts or they should not be physicians at all.