June 27, 2008 11:27 AM
Protecting the
Consciences of OB/GYN’s
June 24, 2008
A recent issue of the Journal of Clinical Ethics published a series of articles addressing the question, to what extent should the consciences of obstetrician-gynecologists (ob/gyns) be protected? The importance of the question lay in the fact that ob/gyns may receive requests to perform controversial sexual or reproductive procedures. Such sexual/reproductive practices as prescribing contraceptives, undergoing in vitro fertilization, and abortion may be requested by the patient. Since all of these procedures are unfortunately legally protected, the physician who has an objection against any of them risks violating the legal “rights” of the patient. That is, there is an apparent tension between the patient’s legal right to have access to the above procedures, and the conscientious physician’s moral integrity in refusing to do them. Similarly, the moral integrity of pharmacists has been attacked by the recent position taken by the American Medical Association's Board of Trustees. The AMA position “supports legislation that would require individual pharmacists and pharmacy chains to fill legally valid prescriptions or to provide immediate referral to an appropriate alternative dispensing pharmacy without interference” (see Proceedings, June 17, 2008).
Edmund Pellegrino contributes a commentary in this series of articles, and I agree in toto with his position. But the other articles take a different stance on this issue. The basic argument seems to be the following: begin by countenancing the apparent tension mentioned above; stipulate that (1) the physician’s professional role is to perform clinical duties consistent with his or her fiduciary duties to the patient, and (2) this professional role ought to be impervious to the moral commitments of the physician. Therefore, the physician ought to comply with the requests of the patient, or at the very least transfer the patient to someone who will. Of course, (2) is patently false. But in its defense proponents make a subtle though quite devastating move. One way to argue for (2) is to equate personal moral commitment with one’s religious beliefs. That is to say, to the extent that one’s moral commitments are “rooted” in one’s religious convictions, they are religious claims, not moral ones. And if they are religious claims, then they ought not to infect the physician-patient relationship. Otherwise the physician is guilty of “paternalism” or of “shoving religious views down the patient’s throat.”
Another way to argue for (2) is to say that the physician’s specifically clinical judgment ought not to be informed by his or her personal moral commitments. A clinical judgment is one that is tethered to reliable clinical evidence of expected benefit vis-a-vis the available alternatives. And, what counts as a benefit is determined by the patient, not the physician. So, if the physician were to refuse to perform an IVF procedure, the physician is defining what the benefits are, not the patient. The patient sees the benefit of “having children.” The physician sees having children as a benefit, but for IVF, this is by means of destroying other children and violating the nature of the conjugal relation. In the end, the values of the patient matter, not the physician’s.
Though I think this pattern and the various justifications for each step are open to an extended analytical critique, I have space only to make some broad comments in criticism of them. Notice the strategy behind the pattern. It is either to reduce the physician’s professional role to making expert statistical judgments, or it is to reduce the physician’s moral commitments to religious ones – and then excluding religious beliefs from infecting the physician-patient interaction. In either case, an important bifurcation takes place between medical judgments and ethical ones. In fact, it is common to see in the literature on this issue (i.e., the issue of conscience) a distinction drawn between medical concerns and moral ones, between clinical judgments and ethical judgments. But such a bifurcation is a grossly inapt description of the physician’s task. The task of healing the person is an inherently moral task. A physician friend of mine, after I told him I was doing research on a bioethical issue, said it best: “I did bioethics all day too.”
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