Dallas Morning News, February 8, 2007
Silent
treatment: Doctors' morals can limit options
Study finds significant minority don't feel obligated to discuss
all procedures
By JEFFREY WEISS
Millions of Americans have doctors who may
not tell them about morally controversial medical procedures,
according to a study published in Wednesday's New England Journal
of Medicine.
A significant minority of physicians who
responded to a survey conducted by researchers at the University
of Chicago said that doctors are not obligated to tell patients
about procedures that the doctors object to, or to refer the patients
to other doctors.
Doctors who consider themselves more religious
were more likely to approve of restricting information than doctors
who said they were not religious. Female doctors were more likely
than their male counterparts to say a doctor is obligated to disclose
all information.
"The general teaching is that doctors
need to be candid and open with their patients," said Dr.
Farr Curlin, lead researcher on the study. "I think doctors
are ethically obligated to be candid."
He said he hoped the study would prod patients
and their doctors into discussing these ethical questions, so
that patients will know where their physicians stand.
The study asked about three morally controversial
procedures: sedating dying patients to the point of unconsciousness,
providing abortion for failed contraception, and prescribing birth
control to adolescents without parental approval.
Doctors who said they had moral objections
to one or more of the procedures also were more likely to say
they did not feel obligated to tell their patients about them
or refer patients to doctors willing to perform the procedures.
For the representative sample of American
doctors, 86 percent said that doctors were obligated to tell their
patients about all medically available procedures, and 71 percent
said doctors were obligated to refer patients to colleagues who
did not object to a medical procedure. And 63 percent said they
believed it was ethical for doctors to explain their moral objections
to their patients.
Doctor knows best?
While patients have the legal right to determine
their treatments, as a practical matter, many don't contradict
their doctors, said Dr. Tom Mayo, a medical ethicist and professor
at the Southern Methodist University law school and UT Southwestern
Medical School.
"You see it in end-of-life care, people
who are reluctant to raise an issue that bothers them because
they don't want to get the doctor mad at them," he said.
That means a doctor who isn't careful can
coerce a patient into a treatment the patient might not want,
he said.
Getting information about alternatives from
the doctor may be less important for many patients today because
of the Internet, said Dr. James T. Norwood, president of the Dallas
County Medical Society and an obstetrician and gynecologist who
practices at Baylor University Medical Center at Dallas.
"Many patients come in and already
know the alternatives," he said. "They are coming to
me for guidance."
And that's where doctors have a moral obligation
to disclose their biases, he said.
"You have to let the patient know that
these are my personal biases or beliefs without using those biases
or beliefs to embarrass the patient or to force the patient to
make a decision they're not comfortable with," he said.
The question of doctor disclosure and referrals
is even more important in rural areas, where a patient might not
have a convenient alternative, Dr. Norwood said.
The survey in Wednesday's report was taken
in 2003 and included a random sample of 1,114 doctors. The results
offer 95 percent confidence that the margin of sampling error
is no larger than plus or minus 3.5 percentage points, and for
some questions the margin was much smaller, Dr. Curlin said.
While religion and gender were factors,
age was generally not. So recently graduated doctors apparently
understand their ethical obligations about the same as their older
colleagues.
Duty to patients
Dr. John Sadler teaches the "Clinical
Ethics in Medicine" course at the UT Southwestern Medical
School. The response of his students mirrors the new survey, he
said. He tells his students that they have an obligation to give
their patients all relevant information.
"Because the physician's duty is to
patients, she is obligated to disclose medical options that society
has legitimated, however controversial in the moral or religious
sphere," he said.
But that doesn't mean that doctors are obligated
to perform procedures they find to be morally objectionable, he
said.
Lance Simmons is chairman of the philosophy
department at the University of Dallas, a private Catholic school.
He teaches about medical ethics but said he was torn by the issues
raised in the new study.
Clearly there is a limit to a doctor's obligation
to refer the patient to any procedure, he said, noting how a 1995
episode of The Simpsons turned the question into farce. Homer
wanted to become morbidly obese so he could be declared disabled
and would be allowed to work from home. He asks his doctor for
help:
Dr. Hibbert: "My God, that's monstrous.
I've never heard of anything so negligent - I'll have no part
of it!"
Homer: "Can you recommend a doctor
who will?"
Dr. Hibbert: "Yes."
"I think there's something wrong with
Dr. Hibbert's willingness to refer Homer to a quack," Dr.
Simmons said.
A joke's a joke, but in the real world,
a doctor is supposed to give all information about a medically
available treatment or refer to someone who will, said Dr. Arthur
Caplan, a bioethicist at the University of Pennsylvania.
"If you are withholding information
on your own moral grounds, you are violating a key tenet of the
doctor-patient relationship," he said.
Dr. Mayo at UT Southwestern agreed.
"If you can't refer patients, you should
probably be in a different line of work," he said.
Dr. Mayo said the new report covers topics
he hears doctors discuss informally once in a while. Based on
those conversations, he was not surprised by the survey responses.
He said he's heard doctors talking about
the decision of some pharmacists to withhold drugs on moral grounds
and not refer patients to another provider. The doctors generally
agreed that pharmacists are a "means to an end" and
should not stand between a patient and doctor-prescribed medication.
"But the next comment," he said,
"is usually: 'But doctors are different.'"
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