To the Editor: The policy of the American Medical Associationstates, "The patient has the right to receive information fromphysicians and to discuss the benefits, risks, and costs ofappropriate treatment alternatives."1 In their study of controversialclinical practices associated with religious beliefs, Curlinet al. (Feb. 8 issue)2 found that many physicians would refuseto tell patients about all legal treatment options in severalcritical situations. The authors advise patients to discussthese issues with their physicians in advance and change physiciansif necessary.
It is unrealistic and unfair to expect patients to anticipateall conditions that may befall them, identify which ones mightbe problematic for their physicians, and agree either to reacha compromise or to seek care elsewhere. Medical visits are shortand focused on current needs. Many people cannot change physicians.People encounter different physicians in different clinicalsituations.
The onus is on our profession to confront the willingness ofso many of our colleagues to substitute their personal valuesfor the fundamental right of their patients to know their treatmentoptions.
Nada L. Stotland, M.D., M.P.H. Rush Medical College Chicago, IL 60637
References
AMA policy E-10.01: fundamentals of the patient-physician relationship. Chicago: American Medical Association.
Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2007;356:593-600. [Free Full Text]
To the Editor: More disturbing than the data described by Curlinet al. is the authors' conclusion: "Patients who want informationabout and access to such procedures may need to inquire proactivelyto determine whether their physicians would accommodate suchrequests." The authors suggest that patients have the obligationto know which procedures they might want or need and to querytheir physicians about whether they would provide or even discusssuch procedures. The unspoken corollary is that if the physiciansays no, the patient is left to find a more responsive provider.To impose the philosophy of caveat emptor is morally inadequate,given the differences in power and class between many physiciansand their patients. Physicians must not be permitted to disavowresponsibility on the grounds of conscientious objection; rather,such practitioners must choose careers in which their fundamentalvalues do not interfere with the autonomy and well-being ofpatients. Like conscientious objectors to military service,medical conscientious objectors must bear the consequences oftheir beliefs. A philosophy that permits physicians' rightsto trump their obligations to patients is unconscionable.
Lainie F. Ross, M.D., Ph.D. University of Chicago Chicago, IL 60637 lross{at}uchicago.edu
Ellen W. Clayton, M.D., J.D. Vanderbilt University Nashville, TN 37232
To the Editor: Curlin et al. provide documentation that patientsmay not receive information about medical options because ofthe religious beliefs of their physicians. The history of Polandshows how a conscience clause can lead to the systemic deprivationof services. The Catholic Church's significant influence inthe post-socialist government, after 1989, led to the widespreaduse of the conscience clause, with de facto elimination of accessto abortion, prenatal diagnosis, and most contraception. Fouryears later, the law actually criminalized abortion services,except in rare conditions, but abortion had already been madevirtually inaccessible because of the use of the conscienceclause.
Similarly, access to services is reduced in the United Stateswith the mergers of nonsectarian and religious hospitals whenreligious restrictions are adopted by the merged entity. Surveyresearch found that the scope of the care that doctors providein such hospitals is significantly narrowed by the impositionof the conscience clause, especially limiting access to emergencycontraception.1
Joanna Z. Mishtal, Ph.D. Wendy Chavkin, M.D., M.P.H. Columbia University New York, NY 10032
To the Editor: The findings of Curlin et al. are timely for Chile, where there is a fierce controversy about whether themorning-after pill should be prescribed for girls as young as14 years of age without their parents' consent. The Chileangovernment, through a presidential decree, introduced the pillas a public health intervention. Opposition parties and theCatholic Church are against this new policy, stating that thepill is an abortion method and is illegal under Chilean law.
Those implementing this policy will certainly face difficulties.Physicians and pharmacists may object to the policy or evenrefuse to distribute the pill on moral or religious grounds.A health care system must establish clear criteria to allowthe right balance between paternalism and the autonomy of patientsin the case of medical issues that are controversial among healthcare professionals.
Victor Zarate, M.D. University of York York Y010 5DD, United Kingdom vz503{at}york.ac.uk
To the Editor: Curlin et al. note the association between physicians'religiosity and their decreased willingness to refer patientsfor interventions that the physicians find morally objectionable,and the authors place this association within the context ofpaternalism versus patient autonomy. However, as physiciansin the "high religiosity" category, we suggest an additionaldimension. Paternalism and autonomy are principles based onrights: the right of physicians not to violate their own consciencesand the right of patients to decide what to do. In counterpoiseto rights are responsibilities. Because of our responsibilityto our patients, we certainly cannot willfully harm them, butwe also cannot assist them in harming themselves without failingour responsibility. If we truly believe that a given procedureviolates patients' intrinsic human dignity, then our responsibilityto our patients mandates that we not help them procure thatprocedure. Thus, although our conscience is part of the picture,so too is our responsibility to our patients. Some circumstancesdo not allow us to assist in carrying out our patients' desireswithout violating that responsibility.
Patrick O'Connell, M.D. 2304 Wesvil Court Raleigh, NC 27607 oconnp{at}yahoo.com
Jacques Mistrot, M.D. Westchester Institute for Ethics andthe Human Person Raleigh, NC 27609
To the Editor: Until recently, I was an attending physician for patients with spinal cord injury during their initial rehabilitation.Many of those patients were on life support and despaired ofgoing on with life, voicing a request for termination of theirlives. Decisions based on patient autonomy alone would havehad us doing so. Negotiations to "give life a try and wait atleast a year before making any decisions" were successful andrequired frank discussion of the patients' values as well asmy own. Most of my patients did find value in their lives aftersuch injuries.
The "moral compass" of a physician should not be ignored. Bothpatients' autonomy and physicians' values must play a role.Coercing physicians is no more defensible than coercing patients.
Kenneth C. Parsons, M.D. University of Texas Health Science Center at Houston Houston, TX 77005
The authors reply: If a judgment of conscience were merely astatement of personal preference or an expression of prejudice,the claims of Dr. Stotland and Drs. Ross and Clayton would bejustified. But anyone who has been hounded by a sense that heor she has acted wrongly knows that is not how the conscienceworks. Those who act conscientiously do not "disavow responsibility"and "substitute their personal values for the fundamental rightsof their patients." Rather, they are engaging in the struggleto know and do the right thing and to understand and fulfilltheir moral obligations in a particular situation. This taskcannot be externalized or delegated. Indeed, acting conscientiouslyis the heart of the ethical life, and to the extent that physiciansgive it up, they are no longer acting as moral agents.
Of course, the profession of medicine cannot permit all purportedjudgments of conscience. For example, the profession cannotpermit physicians to refuse treatment of the sick on the basisof a patient's ethnic background or sexual orientation. Suchrefusals undermine the primary goal of medicine, which is torestore the health of those who are sick. But the practicesabout which we surveyed physicians were not examples of treatingsickness or restoring health. Unwanted pregnancy may have healthrisks associated with it, but it is not an illness. Terminalsedation is not the treatment of illness, unless the illnessis consciousness itself. These practices are controversial preciselybecause there is disagreement about whether they are consistentwith the goals of medicine.
With respect to controversial clinical practices, therefore,individual physicians should consider the moral arguments, takeinto account the particulars of each situation, and conscientiouslydetermine the degree to which they can accommodate patients'requests. If they cannot in good conscience accommodate certainrequests or help patients obtain certain legal procedures, theyshould, as a matter of respect, make that clear to patientsat the earliest possible point. Ensuing discussions can enhancepatient autonomy by allowing patients to make informed decisionsabout which doctor they want to entrust with their care.
Conscientious practice in a pluralistic world is messy evenwhen peaceable. Yet the alternative is a society in which physiciansare required to forfeit conscience in order to join the profession.Patients will not be well served by moral automatons who shapetheir practices, without struggle or reflection, to the desiresof patients and the dictates of whatever regime is currentlyin power.
Farr A. Curlin, M.D. Ryan E. Lawrence, M.Div. John D. Lantos, M.D. University of Chicago Chicago, IL 60637 fcurlin{at}medicine.bsd.uchicago.edu
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