Editor's note: We received many letters on the Perspective articleby Charo (June 16 issue).1 We publish two from each end of thespectrum.
References
Charo RA. The celestial fire of conscience -- refusing to deliver medical care. N Engl J Med 2005;352:2471-2473. [Free Full Text]
To the Editor: With regard to the Perspective article by Charoon conscience clauses, I am disappointed by the treatment ofa very serious topic in medicine. The debate over conscienceis an important one for both providers and patients. Charo offersdistortions of the proposed Wisconsin law, as well as a verybiased approach. Even the title frames the discussion in termsof the refusal of care. I urge readers to read the proposedlaw for themselves.1 In the included legislative analysis, itis plain that the law would leave in place current law thatdeems it unprofessional to fail to make a good-faith effortto refer a patient.
It is also surprising that Charo does not mention the protectionin the bill for nurses, medical students, and others in employeerelationships who are being fired, harassed, and coerced intoactions that they find morally troubling. It seems to me thatshe would be the "moral busybody" in forcing a medical studentor nurse to violate his or her own conscience. That would bethe worst "tyranny." I hope that in the future the Journal willdeal with this topic in an honest and balanced manner.
Matthew Lee, M.D. St. Joseph Regional Medical Center Milwaukee, WI 53210 jamesdad{at}gmail.com
To the Editor: Charo links the "abortion wars" to the refusalby medical personnel to collaborate in certain acts. It is notaccurate, however, to assert that medical care or services arebeing refused. Real medical care and services always respecthuman life. No one should be forced to collaborate in abortion(even when it is achieved through the prevention of implantation),lethal research on embryos, euthanasia, or assisted suicide.Regardless of their legal status, all these acts involve thedeliberate destruction of innocent human beings. Conscienceis indispensable in preventing even remote collaboration inthese and in other wrong actions,1 particularly when the lawfails to promote self-evident ethical principles. Our governmentmay one day legalize the persecution of doctors, nurses, andpharmacists who refuse to act unethically. Until that time,these health care professionals have the right and obligationof conscientious refusal.
Oswaldo Castro, M.D. Howard University College of Medicine Washington, DC 20059
Frederic A. Lombardo, Pharm.D. Howard University School of Pharmacy Washington, DC 20059
Victor R. Gordeuk, M.D. Howard University College of Medicine Washington, DC 20059
References
Wiesel E. Without conscience. N Engl J Med 2005;352:1511-1513. [Free Full Text]
To the Editor: Kudos to Charo for reminding us that doctors, hospitals, pharmacists, and pharmacies enjoy monopolies muchlike those of public utilities — and have commensurateservice obligations. Imagine if electric utilities refused serviceto anyone conducting stem-cell research. At least the victimswould know that they had been cut off. Patients who are refusedall care and information, however — such as the rape victimwho can find no one to tell her where to obtain emergency contraception— are left in a more sinister darkness. A patient justifiablyexpects care providers to use medicine's full powers to relieveher suffering. If doing so makes a doctor or pharmacist uncomfortable,he or she should say so and refer the patient elsewhere. Failingthat, such professionals should post a sign with this language:"To express our religious or personal beliefs, or both, we mayintentionally fail or even refuse to inform you of the existenceof safe, legal therapies meeting your needs." That might restoresome semblance of informed consent. Until then, patient, beware.
David Dobbs, B.A. 18 Winter St. Montpelier, VT 05602 dave{at}daviddobbs.net
To the Editor: It is curious that pharmacists might refuse tofill a prescription. Must all the prescriptions they fill resultfrom morally acceptable diagnoses? The Health Insurance Portabilityand Accountability Act of 1996 (HIPAA) does not allow breachesin confidentiality about diagnoses and therapies so that strangerscan make individual judgments about whether to cooperate intreating a patient. A prescription may be written for a diagnosisof which the pharmacist is unaware (e.g., oral contraceptivesto treat ovarian dysfunction). There are many other people involvedin every patient's care. What if receptionists refused to makean appointment or refused to give the physician a telephonemessage because they did not approve of something? The pharmacistmight refuse to fill a prescription, the cashier might refuseto sell the prescribed item, or the driver of the distributor'sdelivery truck might refuse to transport it. Why is the pharmacist'smoral judgment dominant? Ethically, there should be open disclosurethat some prescribed drugs, products, or services will not beprovided. Disclosure is also ethically required for diagnoses,symptoms, or clinical issues about which the pharmacist, healthcare worker, or others in the chain of health care deliveryhave such feelings that their cooperation in the care of patientsis compromised. Will this trend inevitably lead to a balkanizationof medicine, whereby patients will go only to doctors of theirown sect, who prescribe only for pharmacists of that sect, andrefer only to specialists of that sect? Shouldn't patients bewarned?
Wolffe Nadoolman, M.D., M.B.A. Lafayette Pediatrics Lafayette, CA 94549
Professor Charo replies: With regard to Dr. Lee's comment thatthe proposed Wisconsin legislation does not eliminate a healthcare provider's duty to provide a referral after refusing toperform a service, I would note that Assembly Bill 207 (passedJune 14, 2005, and now pending in the state senate) specificallypermits health care providers' refusals to "participate in"services they find personally objectionable, with "participatein" specifically defined in section 2(c) as "to perform; practice;engage in; assist in; recommend; counsel in favor of; make referralsfor; prescribe, dispense or administer drugs" (emphasis added).
R. Alta Charo, J.D. University of Wisconsin Law and Medical Schools Madison, WI 53706
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