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.