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February 7, 2007
February 7, 2007
Many physicians feel no obligation to tell patients about legal but morally controversial medical treatments or to refer patients to doctors who do not object to those treatments, report researchers from the University of Chicago in the Feb. 8, 2007, issue of the New England Journal of Medicine.
The medical profession appears to be divided, the researchers note, not just in its attitudes about providing controversial practices such as terminal sedation, abortion or birth control for teens, but also in its judgments about what doctors should do when patients request a legal procedure to which their doctor objects.
The study found that although 86 percent of doctors did feel obliged to present all options in such cases, only 71 percent said they would feel obligated to refer the patient to a doctor who did not object to the requested procedure, and 63 percent believed it is ethically permissible for a doctor to describe his or her objection to the patient.
This affects millions of people, the authors note. "If physicians' ideas translate into their practices, then 14 percent of patients--more than 40 million Americans--may be cared for by physicians who do not believe they are obligated to disclose information about medically available treatments they consider objectionable. In addition, 29 percent of patients--or 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."
"Our survey data point to a basic dilemma facing patients and physicians in our plural democracy," said study author Farr Curlin, MD, assistant professor of medicine and a member of the MacLean Center for Clinical Medical Ethics at the University of Chicago. "Because patients and physicians come from many different moral traditions, religious and secular, they will sometimes disagree about whether a particular medical intervention is morally permissible."
The researchers mailed a 12-page questionnaire to 2,000 physicians from all specialties; 1,144 (63 percent) responded.
They asked physicians if they had objections to three controversial clinical practices. Only 17 percent objected to terminal sedation (sedating dying patients to the point of unconsciousness), but 42 percent objected to prescription of birth control to teenagers without parental consent, and 52 percent objected to abortion for failed contraception.
They also asked physicians about their sense of obligation when patients request such procedures. Should physicians "present all possible options?" May a physician who objects to a procedure "plainly describe why?" If the physician objects, does he or she "have an obligation to refer the patient to someone who does not object?"
The study found that the answers to those questions were highly associated with doctors' sex, religious characteristics and whether or not they personally object to one or more controversial clinical practices. Male physicians, those who were more religious (particularly Catholics and Protestants) and those who personally objected to controversial clinical practices were all more likely to believe that doctors may describe their objections to patients. They also were less likely to believe that physicians must present all options or refer patients to someone who does not object to the requested procedures.
In the past, researchers have consistently found that religious physicians are more likely to personally object to a range of different controversial clinical practices, Curlin said. "This study suggests that those most likely to be asked to act against their consciences are the ones most likely to say physicians should not have to do so."
While 86 percent felt obliged to present all possible options, six percent were undecided and another eight percent felt no such responsibility. Sixty-three percent felt it was ethical to "plainly describe" why they objected to a requested procedure. Eighteen percent felt no obligation to refer a patient to another doctor who did not object, and another 11 percent were undecided about their responsibility to refer.
Such situations raise basic philosophical questions, said co-author John Lantos, MD, professor of pediatrics and medicine and associate director of the MacLean Center. "Is there room within the profession for radically different approaches to care based on moral or religious opinions? Should doctors leave their personal religious beliefs at the door, or are those beliefs such a central element of personal identity that the very notion of leaving them at the door is incomprehensible?"
When the authors mentioned their results to colleagues they drew widely varied reactions. A few physicians thought patients had no right to expect morally objectionable treatments, Lantos said. Others thought that doctors who would deny beneficial treatments had no business practicing medicine. But most took to the middle ground. "They felt that doctors had the right to follow their conscience," Lantos said, "and patients had a right to legal, medically approved treatment."
This middle ground places a lot of the burden onto patients, the authors admit. "Patients should know that physicians are divided on this issue," Curlin said. They may want to "talk to their physicians up front to find out where they stand. If they anticipate areas of moral disagreement, they should try to negotiate acceptable accommodations before a crisis develops."
The Greenwall Foundation, the National Center for Complementary and Alternative Medicine and the Robert Wood Johnson Clinical Scholars Program funded the study. Additional authors were Ryan Lawrence and Marshall Chin of the University of Chicago.