In Defense of a Physician’s Right to Conscientious Objection, Part 2

Guest post by Cheyn Onarecker, MD

Today, I am continuing my comments on the recent editorial against conscientious objections from the New England Journal of Medicine (subscription required). My previous objections to the elimination of protections for conscientious objections included: 1) the importance of maintaining the traditional balance that has always existed between the needs of the patient and the physician, and 2) the fact that medical societies make decisions on the acceptability of certain procedures that are influenced by society and do not represent the views of a large percentage of its members. I will now add a couple more reasons.

Third, it is impractical and unreasonable to demand that persons considering a career in medicine should be prepared to violate their moral convictions. When the Church Amendment was passed in 1973, allowing physicians to be exempt from performing abortions, there was no outcry from the AMA or any other medical society denouncing the law or declaring that rights of conscience were unethical. Since then, the number of laws and provisions to protect conscience rights have increased, not decreased. Philosopher Mark Wicclair explains that modern medicine, in general, has accepted the right of conscientious objection, and no young person entering medicine today believes that their moral and religious convictions are incompatible with a career in medicine. In fact, the AMA issued a directive to medical schools to excuse students from performing activities that violate their ethical beliefs. Not only that, but how would physicians be able to predict that someday their chosen specialty would develop a controversial treatment? Stahl and Emanuel assume that a medical student could choose radiology, but what does the future of radiology hold? Many physicians have stated that they would rather leave practice than to be forced to do procedures or make referrals against their conscience. With widespread physician shortages already affecting the care of our citizens, what sense does it make to eliminate large numbers of talented young people from a career in medicine because they want to practice medicine conscientiously?

Fourth, by rejecting physicians who practice medicine according to their conscience, we exclude the very professionals we need to prevent medicine from drifting from its ethical moorings. The history of medicine is full of ethical catastrophes, and Stahl and Emanuel cite eugenics and the classification of homosexuality as a disease as recent examples. But, according to the authors, medicine returns to its ethical path through a self-correcting process of “reflective equilibrium,” as if by some magical force, the profession spontaneously changes course and begins to right the wrongs that had been committed. But no magical force or automatic process stopped the forced sterilization of women in the early 20th century. Men and women, guided by their conscience, fought for decades to change the hearts and minds of citizens and the medical profession. Where would we be if they had passively complied with the accepted practice of the day? If we remove such men and women from our profession, who will be the agents of reform when medicine deviates from its proper direction in the future?

A recent Annals of Internal Medicine article about teaching medical ethics under Nazism concludes that the lack of “eternal values” in medical ethics allowed them to be coopted by the politics of the day. Those who expressed any conscientious objection to the prevailing thoughts were systematically removed from medical leadership, resulting in practices that are universally condemned today. Dr. Joe Gibes critiques this study in his April 21st article for the TIU Bioethics Blog. He appropriately concludes, “It is precisely because society, government, and politics are so fickle, that it is vitally important that the practitioners of this art cling tenaciously to the universal values stated so simply and starkly in the Hippocratic Oath: I will not kill, whether in the womb or out of it.”

Finally, since they suggest that healthcare professionals should ignore their conscience and follow the dictates of their professional organizations, Stahl and Emanuel appear to be defeating their own arguments. Following their logic, because most of the professional societies oppose their views and accept physician’s conscience rights, the authors should simply keep quiet. Their article, however, implies that they believe there are times when physicians should take a stand against the status quo. Even by their own standards, conscience must have more than just a limited role in medicine. To eliminate the right of conscience would be to jeopardize the ethical foundations of the profession. Instead, we ought to look for ways that we can accommodate those rights in order to provide excellent care to our patients.

In Defense of a Physician’s Right of Conscientious Objection

Guest post by Cheyn Onarecker, MD

In their recent “Sounding Board” piece in the New England Journal of Medicine (subscription required), Ronit Stahl, PhD, and Ezekiel Emanuel, MD, PhD, denounce the rights of physicians and other health care professionals to opt out of certain procedures because of a moral or religious belief. The interests and rights of the patient, they state, should always trump those of the clinician. The only role for conscientious objection, in their view, is a limited one, when the appropriateness of a treatment or procedure is being debated.

Once a professional society determines that a treatment is acceptable, the physician must comply or get out of medicine altogether. Stahl and Ezekiel lament that the American Medical Association (AMA) and other medical societies support conscience rights, but, I believe the arguments they advance to eliminate such rights are not convincing and would jeopardize the future of medicine.

First, although the well-being of patients is one of the primary goals of medicine, there has always been a balance between the needs of patients and physicians. Otherwise, physicians would work 24 hours a day, with no time off for family, friends, or other pursuits. Physicians would be expected to respond to all patient requests, day or night. The question is not whether physicians should put patients’ needs above their own, but where the line should be drawn between the needs of the patient and the physician. In emergencies, a patient’s needs triumph, but other situations are not always so clear. When it comes to requests for treatments that violate a physician’s deepest moral convictions, no physician should be forced to cross over the line.

Second, the decisions by medical societies regarding the appropriateness of certain treatments and procedures do not occur in the idealized manner described by the authors. Anyone who has sat in a hospital department meeting knows how decisions are often made. The person, or persons, with the loudest voices and the most influence can carry the day. I have experienced the wholesale politicking that occurs at national society meetings, where resolutions that have been defeated for years are suddenly adopted as organizational policy because, finally, enough delegates were cajoled into a “yes” vote. And to say, as Stahl and Emanuel do, that medical debates are not affected by cultural and political factors is to ignore history. Physician-assisted suicide (PAS) did not become a legal medical practice in Oregon because the AMA determined that it should be so. In fact, the AMA, the largest physician organization in the country, opposed the practice. No, PAS became legal, because the state legislature passed a law. Likewise, abortion became legal due to the decisions of nine judges.

Given that professional societies can be influenced by shifting social and political trends, we should accommodate the right of a physician to rely on her conscience to decide on controversial practices. For example, the fact that abortion-on-demand is legal does not erase the truth that half of the population and a large percentage of physicians do not support the practice. Physicians who object to elective abortions are considering the well-being of the baby as well as the mother. A 51 percent vote by the members of their professional society will not change their conviction that an abortion would take the life of an innocent human being without just cause. Female genital mutilation (circumcision) is accepted in some parts of the world. If such a practice were to become legal and accepted by some professional society in this country, would those who object to the procedure remain silent and comply? In the milieu of the diversity of moral perspectives in our culture, a physician must sometimes rely on her conscience as a guide to ethical medical practice. I have several more thoughts on this topic that I will continue tomorrow in my next post.

How Minimization Hurts Society

guest post by Christina Sisti

Doctors and nurses are becoming more accustomed to those who are seeking a confirmation of their home diagnosis but how do they know when a patient isn’t telling them everything? Every day we put on our game face or our poker face which minimizes our emotions. Our poker faces are costing us our health. Minimization reduces the chances of a proper diagnosis and the ability for a doctor to treat an illness. Minimization doesn’t begin in the doctor’s office though; it begins in society. For some, not telling or to downgrade a symptom is the socially acceptable thing to do amongst family and friends. Minimization may take three different forms when a person is facing pain, fear or illness: 1. Cognitive distortion 2) Understatements and 3) Social minimization. In each of these forms self-esteem/depression may also suffer from the effects of minimization. I believe minimization creates more harm than good for a person’s physical and emotional health.

Cognitive distortion occurs when the person or others avoid acknowledging and dealing with negative emotions by reducing the importance and the impact of actions which cause the emotions. Some may protect or try to divert attention/confrontation by reducing the negative impact of one’s actions upon another by minimizing the perception or feelings of the person who feels pain. By reducing the behavior and its impact it creates a false feeling of safety for one person while creating a feeling of betrayal or hurt for another. Once feelings, fears or pain has been reduced it is hard for the person who feels pain or fear to speak up and explain how they may feel because their feelings have been minimalized by another. To say anything otherwise would be awkward and place not only themselves in a position of being scrutinized but the minimizer in a defensive position. The risk of being viewed as a “drama queen/king” may not be worth the attempt to right the harm done by the minimization. Thus, a feeling of hurt, unwillingness to extend oneself and voice thoughts becomes suppressed.

Understatements are often rooted in cognitive distortion. They belittle another’s feelings by reducing the strength of someone’s feelings or thoughts. When one says tells another they “don’t feel that bad” or “a little bit” hurt/sick they reduce a person’s feelings about a situation which is occurring. It often times has the effect of a person not speaking out when they are in pain or when they notice symptoms which are troubling to them. By not speaking out the person may not alert their doctor in time for an early diagnosis and treatment. Brushing thoughts, feelings and fears under the proverbial rug may cause a greater pain.

The root of understatements and cognitive distortion lies in social minimization. In society we ask others how they are but never expect an honest answer. We don’t want to hear what is really going on nor do we want to be placed in a position of being asked to help or accepting responsibility for how our actions affect others. Some may argue this is not true but I point to the “poker face” and interchanges in which the “victim” minimizes the effects of actions by brushing them off or using reduction words such as “a bit”, “a little” or “merely.” Society has rules on how we display our emotions, how we talk to each other and how we express our pain. There is a general consensus we must present a strong front and “suck it up” for fear of being viewed as weak or as a hypochondriac.

This need to minimize is insidious. It disallows for expression, reduces self-esteem, increases depression and allows others to manipulate our feelings. I am afraid of going to the doctor despite knowing things are not exactly as they should be. I question how to respond to others once another has minimalized my feelings, I question my own feelings based upon another’s reduction of said feelings. I wonder if I tell how I really feel, seek answers and express my thoughts if I will be viewed as too needy or as an attention seeker. Funny thing is, by not taking action I hold in my pain and fear and only hurt myself. What would happen if we expressed our thoughts, fears and pain in a healthy manner? Could we reduce the rate of depression or increase feelings of self-esteem? More importantly, would the rate of detection for disease and illness increase while morbidity decreased? Could we increase society’s health by decreasing minimization?

Minimization needs to be contained. Before a word is spoken or the attempt to downplay another’s actions or feelings takes over your response: stop and think of your actions and the effects they have on all parties. Conversation, healthy, constructive conversation, may begin a path which leads to increased mental and physical health. Society gains from productive, healthy conversations which seek to uncover fears, decrease pain and examine pain.

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Christina holds a Doctorate of Professional Studies from Albany Medical College’s Alden March Bioethics Institute with a focus on Health Policy and Ethics.

Is complicity important in Hobby Lobby decision?

Written by Jay Hollman, MD

The ethical issue for a pro-life employer (as discussed in the majority opinion) is that of complicity. The issue of complicity is a subject often surfacing in the charity clinic in which I work. As I discuss the reasons for patients to stop using illegal drugs we discuss health risks if applicable. This is unconvincing to some who regard marijuana as no more dangerous than alcohol. But as we discuss complicity with the drug trade and how drug use has made many Mexican border towns effectively war zones with thousands killed, many of innocent bystanders, they get the concept of complicity. If all Americans stopped using illegal drugs, we would not only reduce crime in the U.S. but also in Latin America. Since most of our patients live mostly in dangerous neighborhood where violent crimes are common, they can easily understand how buying drugs can make life difficult for many innocent people.

With their understanding of four of the twenty mandated contraception methods, the owners of Hobby Lobby believe that by purchasing group insurance that offering these options might facilitate one of their employees to engage in an immoral act. But if Hobby Lobby did not offer these 4 contraception methods they would be subject to fines of almost 20% of their annual sales, an impossible burden. It is presumptuous and arrogant for any one group in our pluralistic society to think that they know the moment when human life begins. It is not unreasonable for a person to believe that human life begins at conception. If this is believed then it is wrong to fund methods of birth control that would act to end nascent life.

An American capitalist might disagree with his daughter who believes that it is unethical for her to purchase certain products from China because these companies are excessively polluting the Chinese water and air. But he should be tolerant of her view and, if indeed, there is some truth to the pollution claim, he should be proud that his daughter is willing to forgo certain products or pay a higher price to obtain the product from a less polluting company. In the same way, if we desire a strong pluralistic society, we should laud individuals and companies that are determined not just to the correct thing themselves but are also striving to help others do the correct thing. Hobby Lobby demonstrates that the owner’s religious convictions by not being open on Sundays which cost the company millions.

The tone in the media following the Hobby Lobby has been strident. If this is continued, likely nothing positive will happen in health care reform in the current Congress. Most in health care are ready for some real health care reform. Physicians are struggling with electronic medical records systems that decrease their efficiency and invite fraud. All providers and hospitals are strapped with complex regulations that defy common sense. Millions are still uninsured. Most of the patients in my charity clinic cannot afford even the cost of Bronze Plans on the Exchange. All the while we are wasting an estimated $910 billion dollars per year on medical diagnoses, treatments and overhead that do not provide any benefit. Reduction of waste should be a high ethical priority upon which we all should agree. The ACA has started the process of reform by such measures as eliminating lifetime caps on health insurance, allowing young adults to remain on their parent’s health plan and eliminating the pre-condition clause that made insurance unaffordable for those with chronic conditions.

It also must be remembered that ACA is, from its very beginning, a partisan act. Continued litigation will not unite the country but compromise can. Forcing individuals and their companies to act against deeply held religious belief should not be done and will only inflame partisan rancor. This issue in itself is small compared to the large task of completing health care reform. One could hope that both sides might see this decision as an opportunity to change the rhetoric and sincerely work on a compromise plan that would extract waste from our current system and make health care available and affordable to all.

Bioethics @ TIU guest author Jay Hollman teaches at LSU Health Science Center and cares for mostly indigent patients. Dr. Hollman is a 2012 graduate of Trinity’s MA in Bioethics program.

A Lament For the Loss of Community

This guest post is authored by LL French, a current student at TIU.

Community is dead. Cause of death: uncertain. But definitely dead, gone, passed, slipped on a banana peel, deceased, dead!

For Millennials like me, we’ve never lived in a world where neighbors help each other. After all, isn’t that the job of the government? Welfare? Food stamps? Medicaid? (Please note the heavy tone of sarcasm in my voice right now.)

Let me explain the reason behind my cynical rant on community. Today my little bioethics-obsessed mind ran across a CNN news article. In the story, Baby Pierce, a four-month-old with rare Heterotaxy Syndrome, needed heart surgery. Demanding the best care for her infant son, Pierce’s mother insisted on sending her baby to a top Boston hospital for his care.

Problem: Medicaid wouldn’t pay to send him to Boston when another “capable” hospital existed in Indiana.

Solution: fundraising on Facebook and donations from mothers of children with heart problems!

Now for the quote that convinced me that community was dead – in the words of Pierce’s mother: “I think it is sad that a bunch of moms and strangers who don’t even know me or my child have stepped up to the plate more than… the government, and insurance, and Medicaid.” This statement troubles me. She thinks “it is sad” for strangers to help? Isn’t that the very essence of community? Isn’t community, by definition, any group of people that come together to encourage, support, and protect you?

Should Medicaid have helped the young mother? I’ll leave that question to more capable minds. What I am shocked by is the assumption that strangers shouldn’t help! I fear we now live in a world where we rely on the government too much. We rely on the government to be the Good Samaritan that we once were. I mourn the loss of a traditional community where generosity to those in need was normative. Indeed, I fear bioethics and health care in general has much to lose if community dies.

Yes, I exaggerate. There is hope. Community is not dead, but perhaps transformed? Yes, we don’t live in a world where neighbors help each other. Instead, we live in a world where random people on Facebook can form a community to save a baby! Our traditional sense of community has been replaced by Facebook, Twitter, and texting, etc. As a natural cynic, I doubt Facebook’s power to bring people together in community, but Baby Pierce gives me hope that people can come together to form a new kind of community – but only if we are intentional in our pursuit of community and we lose this silly notion that strangers shouldn’t help each other.

See more on Baby Pierce