Friday, May 4, 2007

New England Journal of Medicine Editorial Debate on Health Care Right of Conscience

Discussing a study of controversial clinical practices associated with religious beliefs and physician rights of conscience published in the February 8, 2007 issue of the New England Journal of Medicine, (Curlin, et al., 356 N. Engl. J. Med. 565, 593-600 (2007)), readers of the Journal and the authors of the study engage in a revealing dialogue about conscience rights in the current issue. See "Religion, Conscience, and Controversial Clinical Practices," 356 N. Engl. J. Med. 18 (May 3, 2007), available here. The springboard for this discussion is the conclusion by Dr. Farr A. Curlin and his co-authors, of the University of Chicago, that "Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests." A U. of Chicago colleague, Dr. Lainie F. Ross (with Dr. Ellen W. Clayton of Vanderbilt University), finds this conclusion "disturbing":

To impose the philosophy of caveat emptor is morally inadequate, given the differences in power and class between many physicians and their patients. Physicians must not be permitted to disavow responsibility on the grounds of conscientious objection; rather, such practitioners must choose careers in which their fundamental values do not interfere with the autonomy and well-being of patients.
Dr. Nada L. Stotland of Rush Medical College in Chicago concurs: "The onus is on our profession to confront the willingness of so many of our colleagues to substitute their personal values for the fundamental right of their patients to know their treatment options," she writes. Other correspondents compare the exercise of health care conscience rights motivated by sincerely held religious beliefs to the Roman Catholic Church's influence in post-Soviet Poland, which they claim "led to the systematic deprivation of services" and "de facto elimination of access to abortion, prenatal diagnosis, and most contraception" (Dr. Joanna Z. Mishtal and Dr. Wendy Chavkin of Columbia University); and to the Chilean government's current efforts to make emergency contraception available to minors as young as 14, where the Catholic Church's opposition and the exercise of individual physician conscience may present "difficulties" for the implementation of the policy. (Dr. Victor Zarate, University of York, U.K.)

For the defense, correspondents calling themselves "physicians in the 'high religiosity' category" remind readers that the dialogue is not just about "rights," but about doctors' respective responsibility to do moral good, especially to their patients. "If we truly believe that a given procedure violates patients' intrinsic human dignity, then our responsibility to our patients mandates that we not help them procure that procedure," say Dr. Patrick O'Connell of Raleigh, NC and Dr. Jacques Mistrot of Westchester Institute for Ethics and the Human Person. Dr. Kenneth Parsons of the University of Texas Health Science Center at Houston weighs in with anecdotal evidence of the dangers of vaulting patient autonomy over physicians' conscience. As an attending physician for patients with spinal cord injury during rehab, Dr. Parsons recalls, he heard many patients who were on life support voicing a request for physician assisted termination. Negotiations to "give life a try" were usually successful, he reports, and most of his patients found value in their lives after a frank dialogue about the patient's and the physician's respective values.

The authors of the study (along with Dr. Curlin, Ryan E. Lawrence, M.Div. and Dr. John D. Lantos), offer a thoughtful response:
If a judgment of conscience were merely a statement of personal preference or an expression of prejudice, the claims of Dr. Stotland and Drs. Ross and Clayton would be justified. But anyone who has been hounded by a sense that he or she has acted wrongly knows that is not how the conscience works. Those who act conscientiously do not "disavow responsibility" and "substitute their personal values for the fundamental rights of their patients." Rather, they are engaging in the struggle to know and do the right thing and to understand and fulfill their moral obligations in a particular situation. This task cannot be externalized or delegated. Indeed, acting conscientiously is the heart of the ethical life, and to the extent that physicians give it up, they are no longer acting as moral agents.
The authors heartily agree that the profession cannot permit all purported judgments of conscience, such as refusals to provide treatment based on a patient's race or sexual orientation, since such refusals "undermine the primary goal of medicine, which is to restore the health of those who are sick." But the practices about which they surveyed physicians, including abortion and terminal sedation, were not such examples, the authors note. Rather, they say, "These practices are controversial precisely because there is disagreement about whether they are consistent with the goals of medicine." Curlin, et al., conclude with a ringing defense of conscience rights:

Conscientious practice in a pluralistic world is messy even when peaceable. Yet the alternative is a society in which physicians are required to forfeit conscience in order to join the profession. Patients will not be well served by moral automatons who shape their practices, without struggle or reflection, to the desires of patients and the dictates of whatever regime is currently in power.
The entire correspondence, together with the original study report, are a fascinating glimpse into the thoughtful approaches to conscience rights being considered by practitioners and academics in medicine on both sides of the issue.


HonorLife said...

Regarding abortion and terminal sedation, the authors aptly note, "These practices are controversial precisely because there is disagreement about whether they are consistent with the goals of medicine."
There used to be agreement, howerver, that abortion and terminal sedation were decidedly incompatible with medicine. In fact, that agreement extends back to the Hippocratic Oath, through which doctors over the centuries have professed, “I will use treatment to help the sick, according to my ability and judgment, but I will never use it to injure or wrong them. I will not help a patient commit suicide, even though asked to do so, nor will I suggest such a plan. Similarly, I will not perform abortions."
The reason for any disagreement over the past few decades is simply that some individuals have discarded objective standards such as the Hippocratic Oath in favor of their own subjective perceptions. They have done so because they had the moral freedom to disagree with the prevailing standard. How ironic that they would now deny the same moral freedom to others!

Steven H. Aden said...

HonorLife's observations remind us of the process by which a once-monolithic orthodoxy becomes criticized, then subjectivized, then marginalized, and finally censored. The professions of law and medicine are certainly not immune to majoritarian conceit. Here's hoping that reasoned, patient dialogue, such as that demonstrated by Dr. Curlin and his fellow authors, will continue to answer the moral dictators.

Phil said...

As a point of clarification, terminal sedation is NOT sedating people to the point of death. It IS palliative sedation, in that pain medications and other meds are used to relieve symptoms that have otherwise been unrelievable in the end-stages of life. That means that physicians are trying to relieve pain (and presumably some measure of suffering) by sedating the patient.

There is also something known as the principle of double effect, well-known and discussed in Christian moral theology, that addresses the questions of the unwanted, but possible side effect of respiratory depression with the use of certain pain medications. It is well-agreed upon in the ethics community that palliative sedation to unconsciousness for the purpose of pain relief is ethical, both among secular ethicists and relgious ethicists of various stripes, conservative and liberal.

That side, nothing should be intentionally done to hasten death, such as intentionally giving a patient a dose of pain meds beyond what is needed for symptom/pain relief.

Steven H. Aden said...

Phil - We appreciate your observations. At least from a technical viewpoint, your point about distinguishing between terminal sedation and euthanasia is appropriate. The NEJM article described terminal sedation as "administering sedation that leads to unconsciousness in dying patients." Seventeen percent of respondents noted moral objections to that. Unfortunately, because of the massive dosing on an already vulnerable system required for TS, and because of the inherent difficulty in discerning the line between a primary intention of palliative effect and a primary intention of hastening death, TS is a therapy of choice for those who seek to hasten death. Jonathan Imbody of Christian Medical Association has written about this practice in the Netherlands. See In the Netherlands, and probably even in many countries where euthanasia is still illegal, there may not be a discernible bright line between administering sedatives for the purpose of comforting the patient or killing the patient. So morphine can become the drug of choice for doctors bent on “clearing the bed” in those places(see article). It’s tough to prove whether a doctor aimed to comfort or kill, but it may be that the dosage is a pretty good indicator.

Phil said...

Officially, there are several classes of euthanasia. The situation the article pointed out in the Netherlands is well-known in the bioethics literature - involuntary euthanasia. Last I checked, that is still illegal in the Netherlands. The problem is that there is no penalty for breaking said law. Therefore, people get away with murder. I agree that is a real and serious problem.

In the US, the culture is different, and autonomy is given top billing (to both good and honorable ends, as well as pitiful and wrong ends). As such, that puts the United States in a category with a different problem - the problem of vitalism. But that is a separate issue.

The question of palliative sedation to unconsciousness is one that is very much based in motivation, especially in terms of applying the principle of double effect. I cannot claim to read the mind of the clinician to know specifically what their intent is. Even so, that does not make palliative sedation to the point of unconsciousness in and of itself a moral wrong. Based on both experience and literature, I know that it is not that difficult to titrate medications to adequate pain control.

Dosage can be a possible indicator of motive, but not sure-fire. Depending on many factors, including the patient's underlying disease(s) and its progression, how long they have been using certain medications, and their size, a patient may take enough pain medication to put down a horse, but it's just enough to allow them to not be in excruciating pain.

That said, I am sure that if we repeated the NEJM study with different language, we would get different responses. The words we use are very important when it comes to these matters. That is why physicians should not be talking about the withdrawal of care, but the withdrawal of extraordinary life-sustaining treatment.