Thursday, March 29, 2007
Martin Luther at the Bedside
From the March-April issue of the Hastings Center Report.
BY NANCY BERLINGER

The New England Journal of Medicine recently published a study that included data on physicians’ personal beliefs about three controversial medical practices: “terminal sedation” (palliative sedation of a dying patient), abortion after failed contraception, and prescribing birth control to an adolescent without parental permission. Of the 1,144 respondents, 17 percent objected to “terminal sedation”; 52 percent objected to the abortion scenario presented; and 42 percent objected to the birth control scenario presented.

Respondents were also asked about the ethical obligations of physicians who object to any unspecified “legal medical procedure requested by a patient”: 63 percent said it would be ethical for physicians to “plainly describe” their objections to the patient, 86 percent believed that the physician should provide complete information to the patient, “including information about obtaining the requested procedure,” and 71 percent believed the physician should refer the patient to another provider. Then the researchers did the math: “If physicians’ ideas translate into their practices . . . more than 40 million Americans . . . may be cared for by physicians who do not believe they are obligated to disclose information” about procedures they object to, and “nearly 100 million Americans . . . may be cared for by physicians who do not believe they have an obligation to refer” such patients.

The researchers concluded that “physicians and patients might engage in a respectful dialogue to anticipate areas of moral disagreement and to negotiate acceptable accommodations before crises develop” – a conclusion that a New York Times editorial said “lets doctors off the hook.” Indeed, it is hard to imagine how a dying person, a woman with an unplanned pregnancy, or a teenager who fears pregnancy and, perhaps, her parents, would be in a good place, strategically, “to negotiate acceptable accommodations before crises develop.” All three of these people may already be in crisis.

The NEJM study has other limitations, acknowledged by its authors. The physicians surveyed may have expressed objections to practices they never, in fact, are asked to perform. Their answers do not tell us what they have done, or may do, in practice. Still, the study is important because it is empirical. So much of the “data” on conscientious objection in medicine (refusing to perform or participate in a legal procedure on the grounds of religious or moral conviction) is anecdotal. Media coverage of conscientious objection tends to cast the refusing health care provider in the role of Martin Luther at the Diet of Worms: Here I stand, I can do no other (emphasis on the “I”). Commentators also do this, parsing the rights and responsibilities (but mostly the rights) in a dyadic relationship: Providers versus patients. Paternalism versus autonomy. “I believe” versus “I want.”

In his recent book Partnership with the Dying: Where Medicine and Ministry Should Meet, David H. Smith criticizes “institutional policies of silence” concerning controversial procedures – he is writing of terminal (palliative) sedation and its conflation with physician-assisted suicide – that encourage “considerable clandestine and freelance conscientious objection.” Not all CO cases are dramatic. Sometimes, it’s not about saying no – it’s about not showing up, or about putting off a decision. In Smith’s view, practices like these respect neither the dying, suffering person nor the struggling provider. While institutions may not want to talk about providers’ objections, Smith argues that because the community that deals with impending death must support its members, it should avoid policies that leave providers to struggle alone with their personal dilemmas, which are revealed only when a dying person is acutely suffering. “Honest agonized wrestling with difficult moral issues” should not be “cordoned off from serious discussion of policy.”

Smith’s book offers a useful antidote to the dyadic dilemma. Conscientious objection in medicine is not merely a right to be invoked at the bedside, nor a problem to be held in check through a pro forma conscience clause. Rather, Smith reminds us, openly discussing the nature of providers’ moral objections, while keeping the needs of the suffering person uppermost, is a “difficult and unglamorous” communal responsibility of “morally serious people.” Amen.

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