Friday, February 22, 2008

Is There a Catholic Doctor in the House?


As I’ve said many times before, I tend to avoid philosophical rambles here at No More Hornets. I’m not interested in long, pointless discussions that were much more interesting 2400 years ago when Socrates was stopping strangers in the street and asking them annoying questions. Issues of ethics, in particular, usually bore the shit out of me. In my opinion, the whole universe of ethics boils down to the Jewish version of the Golden Rule, which says, essentially:

Don’t do to anybody else what you wouldn’t want anybody else to do to you.
In more biblical language:
Fuck not thy neighbor royally, if thou wouldst not be fucked in kingly fashion thyself.
But today, I’m going to begin an examination of an ethical issue, mainly by posing a question and suggesting some alternatives. I hope my readers will jump in with comments and we can get a real dialogue going.

So here’s what got me started on this topic.

This evening my wife opens up our local rag, and she notices a front-page story about the mama-papa medical practice she goes to. The headline is: Doctors won’t offer ‘the pill’.

It seems that both husband and wife, described as “two area Catholic doctors” — uh-oh! — have decided that there’s alarming medical evidence supporting their view that swallowable birth-control is bad, bad, bad for women. The ironclad proof supporting their opinion has, unfortunately, been swept under the carpet. In a sneaky disregard for scientific data, our overly permissive society has insisted for years that everybody should be free to have sex willy-nilly with one another, regardless of gender, age, or species.

God works in mysterious ways, and one of those mysteries is why the story of the two doctors made the paper today. They claim to have sent out a letter to their patients way back in October. My wife — one of their patients, as I’ve mentioned — never received it. Perhaps that was because the doctors decided she was well past her child-bearing years and wouldn’t be needing pharmaceutical assistance to keep from getting pregnant. Or maybe they just fucking lied to the newspaper. It's possible that they informed only those patients who actually asked for a prescription. “Oh, sorry, but we think that’s really bad for you, and so does Pope Benedict, and so does Jesus! Do you need any Xanax or anything?”

Anyway, the alleged letter contained some mumbo-jumbo about research that shows how using hormones to prevent pregnancy can lead to a whole world of ills: cervical and breast cancer, deep vein thrombosis, strokes, heart problems, everything but an enlarged prostate. In other words: God is waiting to fuck up your whoring bodies, ladies!

The note failed to mention stigmata, hallucinations, or epileptic seizures on the road to Damascus. Apparently, pill-takers, as opposed to devout Catholics, are safe from those particular diseases.

Now, it so happens that most of the country’s gynecologists dismiss the medical evidence offered up by the Crusading Doctor Duo. That’s probably because most of the country’s gynecologists did not attend the recent conference of the Catholic Medical Association, nor did they feel themselves “convicted spiritually” to stop prescribing birth control.

(As an amusing side note, the news article contains the not-so-startling information that Mrs. Doctor is about to pop her fifth child. As soon as she does, she and her husband would like to begin proselytizing for “natural family planning.” That method has clearly been hugely successful in their household.)

Is the pill risk-free? Of course not; what drug is? But the medical evidence, standing by itself, is certainly not sufficient to warrant a refusal to prescribe birth-control to patients. The two Papal Physicians have clearly allowed their scientific judgments to be swayed by religious, not medical, concerns.

Which brings me to the ethical issue that I’d like to throw open for discussion.

The way I see it, one can view a doctor’s responsibility in five ways:
  1. A doctor has a responsibility to do what a consensus of well-informed medical professionals, based on the best scientific data, would think is right for the patient.

  2. A doctor has a responsibility to do what he believes is right, regardless of the patient.

  3. A doctor has a responsibility to give his patient the best advice he can. But then he should follow his patient’s wishes, whatever they are, as long as they’re not illegal.

  4. A doctor has a responsiblity to think of the greater good, even if it means acting against a particular patient’s best interests.

  5. A doctor has no more responsibility than any other person who performs a service. He ought to be able to pick and choose the specific jobs he does.
There may be other alternatives, but those ought to get the conversation rolling. My own view is number 1, although I'm not sure I can justify it philosophically. As a one-time libertarian, I have difficulty dismissing number 5.

What do you guys think?

58 comments:

Lifeguard said...

As a great lover of philosophical rambles, particularly when it comes to ethics, I loved this post.

Regarding your views of a doctor's responsibilities, I'm inclined towards number three (assuming we're talking about a patient in full possession of their faculties). Maybe it's the lawyer in me, but I always feel like my job is to present the options, give my client the pros and cons, and help them arrive at the decision they feel most comfortable with. Doctors, as I see it, should do the same.

All things considered, if a doctor follows option number three, obviously they should incorporate option number one as that's the most responsible thing to do when you're presenting the alternatives to someone.

theparentheticalatheist said...

I think that number one is the ideal. I also think that the patient has the right (and duty) to tell a doctor who uses religion to determine proper treatment, "Goodbye." And tell the doctor why the patient (and money) are going elsewhere.

PhillyChief said...

First, I think your doctors are lying.

Second, as to my number choice, I can't pick one. #1 sounds right, but what about circumcision? It's still the status quo option, is it not? General consensus is it's best but there's a growing opposition to it in the US. Look at your tonsils. It's been pretty standard all my life that if someone, especially a kid, has some troubles there, out they come. Now some are thinking they play a larger role in our immune system then first thought. When I was a kid my dentist wanted to yank my wisdom teeth, not because there was anything wrong with them or that there wasn't room for them (easy with the big mouth jokes, you smartasses) but because that's just what you do. He gave some stupid excuse about how it'll be harder when I'm older. Wtf? So in light of this and as a cynic, I can't completely trust that the consensus of doctors might be right so a doctor should have the ability to be a maverick and not snip penises, snip tonsils or yank wisdom teeth (I just realized I have a theme of extraction going on here).

So I can see #2, but shit like your catholic doctors' beliefs should be on their signs, their cards and next to their names in the big book of doctors you get from your health insurance company when you have to pick your primary care physician. They can't be covert catholics.

#3 I see as potentially bad. People could ask for all kinds of crazy shit done to themselves. #4 sounds scary but there might causes for this. #5 sounds a bit like #2, but once again if you allow this then they would have to list their services like a mechanic or plumber. You can't have to wait until you're in the consultation to find out your doc doesn't perform this or that service.

This is going to be another of those long debates I guess, probably worse and more complicated than the Kevorkian thing.

the chaplain said...

I'm with Lifeguard on this one. I choose door #3, with the understanding that it implicitly includes #1. I'm an adult woman and I'm not going to allow a doctor to simply to impose what he or she thinks is right upon me. He or she can advise and recommend, but it's my body and I'm the one who will have to live with the consequences of my decision, so it will be my decision.

This whole thing of doctors and pharmacists picking and choosing what they will prescribe or dispense on the basis of religious beliefs, or whether they will wash their hands before surgery, for god's sake, because of religious norms, is ludicrous. Philly is right in suggesting that doctors who limit their services in significant ways because of religious beliefs and practices should inform patients of that fact right up front. Too bad for them if they lose patients because of it.

the chaplain said...

A problem I have with #5 is that, as a society, we've already decided that there are limits to an individual's rights to refuse services to others. Consider the case of a waitress refusing to serve an African-American at a lunch counter. Our society has mandated that she cannot refuse to serve that diner. To do so would result in the termination of her employment and a lawsuit.

Should doctors have more leeway than waitresses? Let's say I start hemorrhaging, go to the nearest ER, and the physician on duty is a conservative Muslim. Can he refuse to treat me because I'm a) a woman, or b) a woman who, according to his religion, is unclean because I'm issuing blood? I certainly hope not. My life depends on him not having that choice.

Sorry, IMO, #5 is not an acceptable option in a democratic republic.

Lifeguard said...

Given Philly's comment, I'm going to modify my support for number three with the proviso that obviously a doctor should not perform just any old kind of surgery someone asks for. I hadn't even thought of that possibility, but I think it'd be covered by the Hippocratic oath to "do no harm."

Chappy, your comment about doctor's limiting their choices based on religious beliefs goes beyond even individual doctors. Catholic hospitals have all sorts of restrictions on that sort of stuff too. I had a pregnant client who had to be transferred from a Catholic hospital, because she wanted to have an abortion. I'm not even sure if the doctors were officially permitted to counsel her on it (they did anyway). I think that's actually a major ethical dilemma for any physician working in a religious institution.

Weird...

PhillyChief said...

I'd say that Chaplain's hypothetical muslim doc or anyone like him would be barred from being able to work as an emergency physician. That's the breaks, cupcake. That's nice you have a conscience or whatever but guess what? That conscience just cost you a job, doc. I think this is an issue they're having in the UK now, with muslims wanting jobs where they'd have to do something against their religion then expecting to not have to do those things once hired and when naturally they get passed over for the jobs, they bitch. Ridiculous.

Your proviso Lifeguard opens the door for many weird interpretations I'm sure. What constitutes "harm"?

I'm starting to realize that this kind of behavior can only lead to a completely segregated society which I think would be too chaotic. Perhaps there has to be some ruling by the AMA that refusing care based on religious grounds could cost one their license to practice medicine. Of course then you'd get clever new "reasons" for justifying the decision, like what they're doing now with abortion and how the creationists are cloaking their shit in ID.

Allyson said...

I pick #3 as well. I want a trained, well-informed doctor to diagnose me properly and give me the best treatment advice possible. But I also want the freedom to disagree with that advice and have control over my body and what I do to it medically.

Of course, I'm not sure how that fits in with children (i.e. parents who don't want their kids to have blood transfusions b/c it's against their religious beliefs). I want to say that the doctor should have the ultimate decision in that regard, because a 6-year-old can't necessarily make major decisions like that. But I'm not entirely comfortable with that. It seems to me that's what's best for the child, though.

Spanish Inquisitor said...

I'm not sure that your five choices resolve the matter. I think anyone that brings their religious beliefs into an area that depends primarily on science (medicine fits that bill - we'd have no medical professions without science, witch doctors notwithstanding) should either suppress their religious beliefs in order to be a good practitioner, or find another line of work that does not conflict with their religious beliefs. (This is a good example of where science and religion clearly conflict.)

They have a right (unfortunately) to believe any form of nonsense they want. However, when that nonsense restricts their ability to properly do their jobs, then they should find another job. While it may just be a job for them, to us, the public, they are public servants. If they can't give 100%, then get the fuck out.

A similar situation exists where Muslim taxi drivers refuse to pick up anyone with a dog, pork or liquor, because it conflicts with their religious beliefs. Again, if it restricts their ability to perform a service for the public, they should find a job that doesn't present them with such options.

Looking back on what I wrote, I see that #5 is probably the closest to what I'm saying. The doctor has the right to pick and choose, but we have a right not to have a doctor in that position, because we rely on him for our health and even our lives. He either provides appropriate medical care, or he doesn't provide any. What happens if we are in a life and death situation, and he decides that his religious beliefs prevents him from providing life saving treatment? Get him out before he does any harm.

the chaplain said...

Allyson raised a good case with the parents of a minor who, for religions reasons, refuse life-saving treatment for that child. I may be wrong, but I think religious beliefs are the only grounds that western societies allow for such decisions, even when they are undertaken on behalf of minors.

My hypothetical waitress can't refuse to serve a diner of the wrong skin color - unless she can justify it on religious grounds. In that case, she just may get away with it in today's climate. Lifeguard's religiously-sponsored hospitals and doctors cite religion as a good enough reason to refuse what society at large deems to be reasonable service.

Religion gets a free pass that is not extended to other ideologies. Yet, they're the persecuted ones. (smirk)

Ordinary Girl said...

My response was getting long, so I wrote a post.

I'm falling in between Philly and #5. It really depends on whether or not the choice of the patient is being taken away. And emergency situations trump any ability to refuse treatment based on personal beliefs.

The Exterminator said...

There's lots of food for thought in everyone's responses so far, but I'm still torn between numbers 1 and 5, with a smidgen of 3 thrown in. I can also conjure up situations in which 2 or 4 would be the ethic I'd like my society to adopt. To tell the truth, I'm in a quandary, because I can't figure out how to reconcile those different approaches.

One pitfall I do see many commenters falling into here is the question of legality and/or the requirements of a specific political system. But I didn't pose this as a politico-legal problem; I posed it as an ethical one. I'd like to live in a society that derives its laws from its ethics, rather than the other way round. So, ideally, we ought to be able to come to some workable compromise on the philosophical question before enacting any legislation or getting the government involved at all.

Maybe that's too idealistic, though, eh?

the chaplain said...

Exterminator said: One pitfall I do see many commenters falling into here is the question of legality and/or the requirements of a specific political system. But I didn't pose this as a politico-legal problem; I posed it as an ethical one.

As much as I like your Rawlsian idea that laws should be derived from ethics (Rawls is one of my favorite philosophers), I see little value in discussing ethics in the abstract. Since I tend to be a consequentialist rather than a deontologist, I find that the best way for me to get my mind around the ethics of a situation is to look at plausible examples, which necessarily exist in cultural, political, social and legal contexts. The fact that some of us have examined "what-if" cases does not necessarily indicate a lack of awareness that the heart of your question is ethical rather than political or legal. In my case, I'm trying to derive an appropriate ethical position on the basis of the potential real-life effects of particular positions.

The Exterminator said...

chappy:
As much as I like your Rawlsian idea that laws should be derived from ethics (Rawls is one of my favorite philosophers), I see little value in discussing ethics in the abstract. Since I tend to be a consequentialist rather than a deontologist ...

See, the problem with academic philosophers is that they like to throw around a lot of big, unnecessary words like "consequentialist" and "deontologist," as well as references to lesser figures like Rawls. This kind of linguistic nonsense, I believe, is an attempt to make themselves feel more "qualified" to discuss profound issues than the rest of humanity is. But it's also a way to conceal an emptiness of thought behind a wall of hair-splitting, Jesuitical arguments. A truly deep thinker -- which I know you are -- shouldn't have to hide behind obfuscatory language like that.

Really, the question I posed is simple. It requires no advanced degrees in philosophy. The matter can be mulled over and discussed by anyone who speaks plain English. In fact, even a child might have something interesting to add to the conversation.

I didn't ask readers to limit themselves to either "pure" (what you would probably call deontological) ethics or "practical" (what you seem to be characterising as consequentialist) ethics. I just threw out an ethical question, without resorting to any artificial philosophy-class taxonomy.

Nor did I make any reference whatsoever to a pie-in-the-sky philosophical system like Rawls's.

I merely remarked that our ethical ideas ought to precede our legal ones. I didn't say that the ethics had to be abstract; I would never make such an argument. In order to frame laws, we have to think about ethics in the real world. But the alternative to a system in which ethics generate laws is to have a system in which laws are not grounded in ethics.

Hey, wait a minute: you're talking about the Bush Administration, aren't you?

the chaplain said...

Exterminator referred to the use of academic philosophical terms as "a way to conceal an emptiness of thought behind a wall of hair-splitting, Jesuitical arguments." This is true. It's why reading post-modern philosophy induces migraines and/or excessive drinking.

The Ridger, FCD said...

The problem with number 5 is that if for some reason all the doctors you can get to refuse to treat you, what then? And yes I know that's not "abstract ethics", so how about this: being a doctor isn't about what the doctor wants to do. So #5 is out.

The Ridger, FCD said...

(Sorry, I published instead of previewed my previous)

And the problem with number 1, I think, is that it allows the doctor to force choices on the patient that they may not want to make. Should the woman be allowed to kill herself by refusing cancer treatment because she's pregnant? What about cosmetic surgery? What about a host of other things a person may want to do that a doctor may feel is bad for them - smoking, for instance? Should the doctor forcibly confine and detox a smoker/drinker/obese person?

I come down partway between 3 and 4, myself. Vaccinations, quarantines, etc, for instance.

newbie atheist said...

Well, as a doctor (primary care Internal Medicine) I ought to weigh in.
We are TAUGHT that if we have a personal problem with a requested treatment that is otherwise an acceptable medical option in the country (abortion), we very much have the right to explain (not preach) our position to the patient. Even this is only done to explain why we will need to find them a different physician who can indeed perform that service.

We get asked to do all kinds of marginally safe but medically inappropriate and unnecessary things all the time and just plain tell people their request is wrong and why (e.g. diet pills which NEVER result in long term weight loss). I've never been asked, but if a patient said her religion was such that they wanted female circumcision (clitorectomy) performed on their newborn daughter, (that being illegal in this country) I would not have any obligation to direct them to another person to fulfill their request.

Spanish Inquisitor said...

In purely ethical terms, it is unethical to impose your religious beliefs on someone else, in the guise of doing your job. But I still think a doctor can choose to refuse to do something that he believes is wrong. But if his job requires him to do it, then he shouldn't be in that profession.

I knew a OB/GYN who stopped delivering babies, limiting his practice to the GYN side of the profession. His reasons were entirely selfish. He said his malpractice insurance premiums didn't justify the work. Too many lawsuits for difficult births, where they blamed the Doctor. So he just quit. He was certainly within his rights to stop delivering babies. His reason made sense, and was entirely financial (not to mention the reduction in his stress), so why not? It really didn't affect his patients, they knew in advance, and they went elsewhere.

I don't think these Catholic Drs. reasons can be justified in the same way. Objectively, the stated reasons are not born out by the science, and appear to be thinly veiled excuses for their religious beliefs. If so, they are lying about the care they impliedly promise to provide to their patients. That makes all of their work suspect. So, not only should one not use their services for contraception, all of their services should be boycotted, are at least avoided.

If no one uses them as a Dr. then they will either re-think their position, or leave the profession.

The problem is, all the holy rollers will flock to them in droves. (Perhaps this was a marketing decision on their part?)

PhillyChief said...

Ex, I think what you want is a dream because we're talking about religion. When religion gets involved, you no longer can count on ethics, you need the law.

Sarge said...

Very interesting thread, since I just got out of the hospital yesterday.

Here in this town we have a Faith Tabernacle church whose members believe in faith healing. There is a family in membership who had two children die, one from a Wilmes Tumor, and the other a seventeen year old girl who died from complications of diabetes.

The girl was taken away from her parents and hospitalised, and her treatment was "forced" as she tried to resist it. (one hears things, apparently some of her care givers grew somewhat frustrated and thumped her before she was put in restraints) She died from her disease, and apparently her family was kept away from her although she wanted them near her.

There's right/wrong/moral/legal questions that are sure too tough for me to figure, along with the fact that ones health is, and for a long time, has been a commodity like food and shelter.

The same groups involved in the anti contraception/abortion movements also used to picket hospitals that anesthetized women in labor since this was thwarting their deity's injunction that women give birth in pain.

The Exterminator said...

If we were talking about a roofer or a gardener or even a lawyer who refused to do something on religious grounds, there would be no conversation. All of us would just say "fuck that," fire the person, and hire another.

So we all seem to agree that there's something different about doctors that puts them in a different category than all other service providers.

But let's grant for the moment that some doctors' religious beliefs would keep them from performing certain duties as well as they could. They're human, too, after all.

So does society:
(1) use a religious test in licensing doctors, i.e., refuse to grant licenses to doctors whose religious beliefs would keep them from performing all medical services for which they're trained;
(2) grant licenses, but require doctors to make their religious beliefs known to all their patients;
(3) grant licenses, not require doctors to make their religious beliefs known, but force them to perform all services for which they're qualified, even in cases where performing those servies would come into conflict with deeply held personal beliefs; or
(4) just let doctors make whatever arbitrary decisions they choose, including those based on religious beliefs?

If the answer is (4), that puts patients in the position of having to investigate not only a doctor's medical qualifications, but also the doctor's religious beliefs. Under what laws would the doctor be required to answer questions about that?

PhillyChief said...

Option #1 across the board, regardless of job, be it doctor, roofer, plumber or President of the US. Mind you, it won't deny a catholic a job, just if that person can't perform his job requirements because of it.

I can't help but keep making comparisons to booze and drugs for religion. I'm not going to discriminate against a doctor or roofer who likes his hootch, but if you show up for work and I smell it, you're fired pal.

The alternative to #1 would be some crazy new categories like catholic doc, muslim doc, or what have you. This would then be equivalent to what I said earlier about these clowns having to post on their door what services they do and don't perform. The title would serve as that. This would also help in what I said at OG's blog, that they might not get included in a Health Plan's directory of doctors, which would be great, along with immediately being excluded from jobs like emergency care. Harsh? No, just showing that there have to be consequences for your choices, and YOU have to pay the consequences, not the people you could be imposing on. THAT'S the lesson the religious have to learn. The bill for their shit should be paid by them, not us.

The Exterminator said...

Philly:

Option #1 across the board, regardless of job, be it doctor, roofer, plumber or President of the US.

Oh, man, do I agree with you. In my ideal world, that Option #1 would be a no-brainer.

But would that then put you and me in the position of having to conform to the same standard. You're an artist; I'm a writer. Can you as a "licensed" artist, or I as a "licensed" writer, be forced to provide our services for work we find philosophically or morally distasteful?

Example: I've turned down two or three jobs creating/editing educational material for textbooks aimed at religious schools. The clients for these jobs were companies for whom I'd already performed many services in the past. As a qualified book "doctor," should I have been forced to render my services despite my philosophical objections? I think that's the logical extension of Option #1 if it applies to all professions.

If you have a client for whom you've done lots of work and he suddenly asks you to create an animation to be used at his Jesus-jumping Web site, can you refuse to provide him with your best efforts? Again, I don't think so -- if Option #1 is made legally binding.

PhillyChief said...

Luckily I don't need a license to practice art. :)

But of course now you've turned it on it's ear. Now instead of a doctor refusing care on religious grounds, you're asking if one should be compelled to perform religiously motivated care. I'd say no, since it's not necessary. Here are some hasty examples:
Religious roofer refuses to work on holy day - Not ok
Roofer refuses to build roof with tiles arranged in a cross or a pentagram - Ok

The Exterminator said...

Philly:
But of course now you've turned it on it's ear. Now instead of a doctor refusing care on religious grounds, you're asking if one should be compelled to perform religiously motivated care.

Well, yes, I have "turned it on its ear." I'm examining what I see as some unpleasant ramifications of choosing Option #1 in my comment above. If I didn't think those unpleasant ramifications existed, I'd be happy to support a law barring anyone from injecting religious or philosophical views into his or her work under any circumstances whatsoever.

But, using your roofer example: How would you justify ethically and then write a practical law that both (1) forbids roofers to abstain from working on specific days because of their religious or philosophical considerations; but (2) allows roofers to abstain from implementing a specific design because of their religious or philosophical considerations?

I can't figure out how you'd do that.

PhillyChief said...

Necessity, mostly. Do you NEED your roof tiles to make a pentagram? No. You need a roof. If a storm is coming or for whatever reason urgency is required, then you may NEED to work your holy day.

I think this is why we're making a bigger fuss in general over doctors vs roofers. It's the need for a doctor and what it means if we can't get one in time or if we get one and they won't care for us vs the same with a roofer. Lack of life is far more important than lack of roof.

heather said...

A great thought-provoking post and fascinating comments.

Sorry in advance for the long and humourless comment you'll be getting from me, here.

I don't think anyone should be obliged to do things they find morally repugnant, whether it's in the job description or not.
It seems silly and offensive when it's catholic doctors refusing to prescribe contraception. BUT
There was mention in New Scientist about US psychologists who've left their association because its members are playing an active part in the US torture model. Now, on your model, the best well-informed professional advice for them is that colluding in waterboarding and sensory deprivation is OK...

(Auschwitz doctors spring to mind as examples of what can happen if you put profession before ethics.)

If I was a doctor, I can think of lots of medical procedures that I would refuse to do, on the basis of my own ethics.

Doctors have traditionally been seen - and seen themselves - as moral arbiters for the rest of us. They had mercifully ditched most of this. (If anything, my own GP-group-practice doctors err on the side of patient empowerment. They expect me to have my own ideas on preferred treatments..)

But, as our societies seem to be getting more and more socially illiberal, it seems that they are getting forced into a new moral guardian role. (As in number 4 and number 2)

There is a constant clamour in the UK, at least, for doctors to become lifestyle police. There are calls for doctors to refuse treatment to people whose eating/ drinking alcohol/ smoking/ exercising habits don't fit the current model. Now the UK government is trying to embroil doctors in their project to cut numbers on invalidity benefit by giving out certificates of what the disabled can do.

Some doctors may feel this is "right" or contributing to the "greater good." Clearly, my idea of right and greater good are completely at odds with these definitions of what's good for society..

Given all that, I'd have to say that number 3 is probably closest to an ethically defensible answer.

Number 5 is also pretty much correct, except that doctors do have more responsibility than, say, a "nail technician." Otherwise, unappealing jobs wouldn't get done and unappealing patients wouldn't be treated fairly. That's where the role of professional bodies is important in setting guidelines to ensure fair treatment.

Number 1 sounds enticing but it violates the principle of control over one's own body. The best medical consensus at any one time is not always right. It's science so it gets modified when there's new information. (Tonsillectomies, electro-shock, thalidomide, etc) Medicine had better be 100% certain before we think it's OK to impose it on people.

Reductio ad absurdum The best medical knowledge is that human organs can get cancerous. Why not remove all body tissue that's not urgently needed? Had a couple of kids? Those genitals and breasts might just cause problems in later life. Get them surgically removed now.

The Exterminator said...

Philly:
Necessity, mostly....I think this is why we're making a bigger fuss in general over doctors vs roofers. It's the need for a doctor and what it means if we can't get one in time or if we get one and they won't care for us ....

I like the necessity argument a lot, and it feels instinctively obvious that a doctor and a roofer are in two different categories.

But how does that apply to a medical practice that refuses to prescribe a birth-control pill? Using my wife's soon to be ex-doctors as examples: their practice is located in a county that has nearly half a million residents. There are many other doctors in the phone book. These other doctors may be more expensive to go to, or less conveniently located, or not as easy to schedule an appointment with at an opportune time. But they're definitely available to patients who want a prescription for a birth-control pill.

I think in some limited instances obtaining that pill may be a life-or-death necessity. But in most cases, it probably isn't. First of all, there are other methods of birth control available (including -- the religious doctors might argue -- abstinence). Second, since there's no time urgency attached to getting that pill (it's not an instantaneous abortifacent), a patient has the opportunity to go to another practice through which a prescription could be obtained. Third, taking the pill actually does entail certain minimal risks. So if the doctor's reservations about writing a prescription are based on her honest medical judgment rather than religious propaganda, even though she holds a minority opinion, isn't it her necessary responsibility not to prescribe that drug?

heather:
Given all that, I'd have to say that number 3 is probably closest to an ethically defensible answer.

Just to repeat number 3 from the post:

3. A doctor has a responsibility to give his patient the best advice he can. But then he should follow his patient’s wishes, whatever they are, as long as they’re not illegal.

So, heather, are you saying that you see nothing ethically wrong with a doctor obeying a patient's wish to be left to die needlessly because the patient doesn't believe in blood transfusions? Or a doctor helplessly shrugging at a patient's refusal to be inoculated against a highly contagious but preventable disease during a deadly epidemic?

Allyson said...

So, heather, are you saying that you see nothing ethically wrong with a doctor obeying a patient's wish to be left to die needlessly because the patient doesn't believe in blood transfusions? Or a doctor helplessly shrugging at a patient's refusal to be inoculated against a highly contagious but preventable disease during a deadly epidemic?

In the case of the blood transfusion, I don't like that patient's decision, and I think they're making it for stupid reasons, but I also think that they have the right to make that decision for themselves. In the epidemic case, refusing a vaccination could cause harm to the greater public, so I don't think it's okay to refuse the treatment. (Of course, in the transfusion case the family will be affected by the death, but the point is that the only person dying in this case is the individual; in the epidemic case, refusing innoculation could have much greater consequences.

The Exterminator said...

Allyson:
I noticed your support for choice number 3 in your previous comment. Sorry that I didn't welcome you personally to my blog; I try to make it a point to greet all new commenters. So hello. Better late than never, I hope. Feel free to say anything you want around here. Don't mind the language, the teasing, or the sniping; some of our conversations can get pretty wild and woolly.

Anyway, getting to your latest comment: How can you ethically justify a doctor's willingness to let a patient die needlessly. This is not an assisted suicide issue, where the patient is doomed to more and more suffering. This is just plain, "Sorry, Doc, but I feel like killing myself. Do you mind not butting in?" Doesn't a doctor have a responsibility to "do no harm." Isn't failing to stop a preventable suicide ethically equivalent to doing harm? In other words, is the doctor under an ethical obligation only when it comes to performing certain services, but under no obligation when it comes to neglecting to perform certain other services?

Allyson said...

Hey exterminator--

No worries about not saying hello or about crazy discussions. This is a busy blog! I don't comment a whole lot on most of the blogs I read, so don't worry if you've offended me if I don't say much. I often prefer to watch a discussion evolve, although sometimes (like on healthcare issues) I have to talk!

Okay, so your post, then . . .
This is not an assisted suicide issue, where the patient is doomed to more and more suffering. This is just plain, "Sorry, Doc, but I feel like killing myself. Do you mind not butting in?" . . . Isn't failing to stop a preventable suicide ethically equivalent to doing harm?

I do see your point here. However, I guess I'm incredibly way-out-there on the issue of suicide. I believe someone should have the agency to end their life, no matter what. Of course, the problem is then how do you explain the pain that this is going to cause friends/family? I admit I don't have an answer for that, but I still believe in ultimate agency. Humans don't really have a choice over whether or not they're born, but I think they should have some control over when they die (although we couldn't ever have complete control over this). If someone would rather die than get a blood transfusion, be my guest. I can see how a doctor failing to prevent what amounts to a suicide is considered harmful, but I have a strong stance on individual/patient agency, and if a person knows they'll die without a blood transfusion but refuses it anyway, I think the doctor has done all s/he can to allow the patient to make an informed decision. But patient choice should win out.

Now, I do see a kind of problem here. What if a patient believes that s/he will live because god will save her/him if s/he resists the temptation to get the transfusion? Is the patient really making an informed choice if her/his religious beliefs make her/him think s/he can survive without the transfusion? Still, I don't feel right just denying individual autonomy to people based on religious belief.

Slobbering Interpreter said...

Now I'm a little curious about the particulars of your wife's ex-doctors' reasoning.

Is it only the "Pill" they object to? Would they, for instance, insert an IUD? OR refer a male for a vasectomy? Or after a C-Section, tie the woman's tubes? IOW, do they refuse to perform all conception related procedures, or is it just the Pill they object to?

If it's just the pill and they feel it's harmful, (as opposed to feeling it encourages promiscuity, i.e. a moral rather than medical opinion), it seems to me that they have the right to refuse to "poison" their patients. But, again, then, the public has the right to consider them crankcases, and leave the practice.

PhillyChief said...

If a patient says, "I know this course of action will result in my death, but that's what I want" then yeah, the doctor should comply or require a mental competency test first and if the patient passes, then do what they want. This is far different than the honoring a patient's refusal of care like blood transfusions because they don't see that as suicidal. That, for me, would be an example of a clear failure of mental competency so the doctor would not have to honor that wish.

Slobbering Interpreter (hereafter referred to as SI2 to avoid confusion with our other SI) brings up a good point and I think is the way you investigate these people's explanations. I think I mentioned here earlier that if you denied them the right to deny care on religious grounds, they could cook up other excuses. SI2's questions probe that by asking if they'll do those other things. I think it would be very difficult to come up with "credible" excuses for not doing those other things, thereby exposing them as really being religiously motivated.

Necessity won't catch everything unfortunately Ex, but it should catch most. I think if you couple necessity with denying religiously motivated refusals of care and you investigate all refusals of care not claimed to be religiously motivated the way SI2 did, then you got most of the problem covered and your catholic docs would not get away with refusing the pill.

The Exterminator said...

Spinach Ingester:
Now I'm a little curious about the particulars of your wife's ex-doctors' reasoning.

I didn't really see this post as being specifically about my wife's ex-doctors. I used their story as a springboard into a philosophical question. So I didn't explore any other issues in the doctors' practice -- although my wife and I have asked ourselves the very same questions you listed.

The story in our local rag doesn't mention any procedures or medications other than oral contraceptives. The newspaper is notoriously error-laden, and the reporters are inclined to print, as fact, any drivel that their interviewees tell them. So I originally chose not to include this part of the story, because it may be completely bogus. But here are some more "facts":

Mrs. Doctor, who had taken the pill for years -- but, of course, with misgivings -- had a sudden awakening when she discovered that she, herself, had been "accidentally conceived." Uh-oh! If her mother had used birth control ...!!! This oh-so-unbearable news caused a spiritual crisis that came to a head at the Catholic Medical Association conference.

So here's a question: In what way does the Catholic Medical Association differ from a medical association that isn't affiliated with any religion? I think the answer to that one is obvious. The former organization closely intertwines medical science and superstition. It's a club for witch doctors and faith-healers. It might as well be called the Voodoo Medical Association.

Ultimately, SI, my wife decided that it wasn't important to be able to answer questions like the ones you pose. She knows that the Catholic Doctors are, at least in one case, allowing their superstitions to influence -- maybe even to take precedence over -- their medical judgments. That's enough to make their practice untenable for her.

Allyson, Philly:
Both of you seem to be saying that a perfectly healthy person should have the right to commit suicide, even with the tacit assistance of a doctor, as long as the person isn't mentally incompetent to make that decision. I assume you'd both categorize a patient's desire to "meet Jesus right now" as a sure sign of derangement.

So, given that the first biological imperative for most living organisms, as long as they're not in unbearable pain, is to stay alive: Can you think of a medical scenario in which a mentally competent person, one who's not afflicted by a disease which causes -- or could cause -- pain or suffering of any kind, would ask a doctor not to keep him or her alive by a simple, risk-free procedure.

I confess that I can think of only one: an organ donation to a loved one. "Yes, kill me (or allow me to die), take my heart, and give it to my child."

But does that example sit well with your views of a doctor's ethical responsibilities? If not, can you think of other examples that suit you better?

PhillyChief said...

Perhaps there has to be a new specialist, a suicide doc. So then when healthy person comes in with request to be killed:
1. Patient is referred to another doc for psychiatric testing
2. Upon passing, they get referred to suicide doc.

Of course the test would probably be a disingenuous step because I believe the desire to die is considered by the psychiatric community as not indicative of a competent mental state.

Allyson said...

So, given that the first biological imperative for most living organisms, as long as they're not in unbearable pain, is to stay alive: Can you think of a medical scenario in which a mentally competent person, one who's not afflicted by a disease which causes -- or could cause -- pain or suffering of any kind, would ask a doctor not to keep him or her alive by a simple, risk-free procedure.

I guess I really can't think of an example . . . The best I can come up with is if someone is diagnosed with cancer, first time, in a treatable stage, and the person just decides they'd rather not deal with chemo and the risk of cancer coming back. But even so, I think the "extended pain" factor is there, at least implicitly.

As for the parent/child example, it does make sense in a way. I don't think that I would be so selfless as to give up a vital organ to save a child (even if it was my own), but I do think the doctor should respect that choice. Of course, that brings up a whole different source of issues: should the person's partner get to have a say over the spouse giving up a vital organ to save their child? If the parent opposes it, if s/he would rather lose their child than their spouse, would s/he be vilified for it? Should a spouse be required to take on single parenthood if the other wants to die to save their child? It almost starts to resemble a pro-choice issue.

Spanish Inquisitor said...

Catholic Medical Association

Strong emphasis on Catholic, very little emphasis on Medical.

The former organization closely intertwines medical science and superstition.

See, this is where the whole science/religion conflict becomes so important. There is no place for religion in science (or medicine). Your wife is right to leave, even without knowing exactly how her doctors would respond to specific cases, because they've already telescoped their reliance on superstition, and that calls into question all of their medical care, not just that related to preventing conception.

Why any Doctor would feel the need to belong to a Catholic (or Voodoo, or Hindu) Medical society is beyond me. There is either a medical reason, therapy or diagnosis, or there isn't, and one doesn't need to look to their religion for assistance.

The Exterminator said...

Philly:
I believe the desire to die is considered by the psychiatric community as not indicative of a competent mental state.

I'm guessing you're right. But it makes you wonder: How can any heaven-believing psychiatrist think that. If heaven's a better place than Earth, why wouldn't every rational person want to get there as quickly as possible?

Allyson:
Of course, that brings up a whole different source of issues ...

I think that's what makes this whole area of medical ethics so fascinating. Every hypothetical answer generates a slew of counter-examples.

SI:
Why any Doctor would feel the need to belong to a Catholic ... Medical society is beyond me.

Well, it's beyond you because you obviously don't take orders from the Pope. You must really wanna go to hell.

Disgustipated said...

I agree with number 1. And 5 on the grounds that practicing medicine is an art so to speak and there is room for picking and choosing. What works for one person doesn't always work for everyone.

The Exterminator said...

Gusty:
practicing medicine is an art ...

Does that give doctors a pass on ethical behavior? Are they allowed to be fucking barbarians like the rest of us artists?

Anonymous said...

I don't think anyone gets a pass on the responsibility to act ethically. That so many choose not to is a reflection of the ideals, or lack thereof, with which they were inculcated in their formative years. As for the issue at hand, I believe, like most other responders here, that the answer isn't contained in only one of the choices but in a blending of the options. To me, options 2 & 4 would be personified in the type of doctors with whom many of us have had the misfortune of dealing over the years. The type who comes to the office daily looking to demonstrate (to his or her satisfaction) an omnipotence bestowed by having spent 8 to 11 years acquiring a medical degree.
I think the answer is a blend of options 1 & 3 with just the right amount of 5 thrown in for good measure. I want a doctor who utilizes the latest scientific data to formulate a diagnosis and treatment plan. I also want him or her to ask my feelings on the subject and to take them into consideration when making a decision. Now, at the risk of sounding trite, doctors are people too. As such I believe they have the same rights to act as their personal ethics dictate that I and the rest of the responders here expect. In light of this, I'd appreciate it if they would post a list of these proscribed procedures on the wall in their office, next to that other notice so many of them have. The one that reminds us of the expectation of prompt payment for services rendered. That way, if I walk in and see that I've wandered into the office of some bible thumping, medical missionary, I can turn around and leave. No harm, no foul.

Catherwood

The Exterminator said...

Catherwood:
In light of this, I'd appreciate it if they would post a list of these proscribed procedures on the wall in their office...

Yeah, that would be nice. But can we write a law that requires them to do that? I don't think we'd be able to enact: "You must post all procedures and medications that your religion forbids you from ..."

That law would violate both religion clauses in the First Amendment.

bullet said...

I don't think it needs to specify the religious objection. A simple sign that states: "For various reasons, we do not provide some common services, including, but not limited to..." would work for me.

I don't think that would make it right, but at least it doesn't waste my time.

bullet said...

Oh, and the AMA's principles of ethics might be a good place to start.

The Exterminator said...

bullet:
Those Principles of Ethics according to the AMA sound great.

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
I don't see where denying oral contraceptives because of religious beliefs fits into this. I think the best interests of the patient are served by not succumbing to church propaganda.

V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
Can a doctor use this item to justify a trip to the Catholic Medical Association conference? Is that studying, applying, and advancing scientific knowledge? Or doesn't such a conference urge its attendees to disregard, hinder, and push back scientific knowledge?

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
And does that include the responsiblity to "save" the patient for Jesus?

The Ridger, FCD said...

For a change of pace, I tag you historically (though you don't have too, of course.

The Exterminator said...

Ridger:
List 7 random/weird things about your favorite historical figure.

Well, I'm flattered that you tagged me, but I'm gonna pass on this one. The truth is: I don't feel like doing the research. Also, I don't have a favorite historical figure.

But here's a cool fact about John Adams: Despite the possibility that it might be career suicide, he agreed to act as a defense counsel for the British soldiers accused in the Boston Massacre.

Sarge said...

My mother-in-law started nursing in 1920, and from things she said and what I heard from some of the other older nurses, they knew of certain doctors "back in the day" who could be counted on to take over a case of a suffering, terminal patient and the suffering
would end on their watch sooner rather than later.

They didn't say much about it, but it seems to have been one of those deep dark secrets that everyone knew.

The Exterminator said...

Sarge:
The same groups involved in the anti contraception/abortion movements also used to picket hospitals that anesthetized women in labor since this was thwarting their deity's injunction that women give birth in pain.

That sounds right to me, but of course I'm biased. I briefly looked on Google for more info about this, but wasn't able to find any. All I found was an ID-er refuting the claim and saying, basically, "You see how atheists make shit up?"

So in the interests of fair play, I guess I should ask you if you can substantiate your statement somehow.

...they knew of certain doctors "back in the day" who could be counted on to take over a case of a suffering, terminal patient and the suffering would end on their watch sooner rather than later.

Again, I don't doubt this. But I guess if we're going to keep "objective," you ought to substantiate that one, too.

Sarge said...

As to the first, I'll have to dig it up in my back copies of SKEPTIC somewhere. Need a bit of time.

As to the second, I admit this to be hearsay (my mother-in-law and the last of her age group are now dead) but they did mention this in my presence on three occasions.

I have a feeling that one won't find much documentation of this, like with VD reports, no matter what the law said. I've found that there is often an institutional blind spot concerning things which "laymen" might misconstrue, especially then when doctors were unquestioned pretty much.

jdavidb said...

Ain't it obvious that there should be competition? We don't want every doctor to be a cookie cutter of every other -- that's a sure way to mediocre medicine and lack of innovation. If some doctors want to be weird, in your opinion, then in America they have the right to be. Go to some other doctor, and let them go bankrupt, or let them serve their niche (which may not include you).

Having every doctor follow "medical consensus" sounds great, but in practice it just means that our very uneducated elected representatives will vote on what medical consensus is. I don't want my life hinging on how good a job the lobbyists did of educating my congressmen.

The idea that "we" should all make this decision together, is just plain wrong. It'll kill the minority of people who might benefit from alternative "crackpot" therapies.

PhillyChief said...

Medical consensus is established by organizations like the AMA. Violating AMA rules and requirements would result in loss of license to practice medicine. I see no place for politicians in this.

generic cialis said...

My philosophy tells me that God works in mysterious ways, and one of those mysteries is why the story of two doctors made the paper that day.

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