Tuesday, January 27, 2009

Conscientia Recta

The girl* was young, so very, very young.  Thin arms and legs, dark circles under her eyes, a surly, muscle-bound boyfriend at her side, a nervous mother who had gotten a wake-up call at two in the morning to meet them at the hospital.

The girl was bleeding a lot.  Her eyes were tired, her face pale.  

"We're sorry for what you're going through,"  the nurses said as they hooked up the IV tubing and got her settled in the O.R. bed.

The mother and boyfriend went to the waiting room with an awkward wave of farewell toward the girl.  She was alone with us, then, bleeding and exhausted, the remains of some "products of conception" not fully evacuated at the clinic she had visited earlier to end her pregnancy.

I touched her head as she lay on the operating table.  "I'll be putting an oxygen mask on you now, and I need you to take some deep breaths, okay?" She nodded.  

A few seconds passed.  Eternity in the space of a few breaths. "How are you doing?" I asked.  "I'll be giving you some medicine now that's going to make you feel really sleepy.  Just keep breathing, all right?  All the way in, all the way out.  That's it, you're doing great."  The drug went in.  Lights out.

It was over in less than ten minutes.  She awoke easily.  Then she began to cry.

"Is it over?"  she asked.

I told her we were just wheeling her to the recovery room.  She began to sob. She cried and cried and cried, so mournfully and so hard that the nurse helping me maneuver the bed started to get tears in her eyes.  I felt that sore tightening in my throat that often heralds the onset of unstoppable tears.  I swallowed and willed it away.  We couldn't all be falling apart here; it would not have been helpful or good for her, our patient.

In the recovery room she gripped my hand tightly.  I just looked in her eyes and said nothing for a few seconds.  I put my hand on her forehead and brushed back her hair.  "You're going to be okay," I said. "You're in good hands."  I looked at the recovery room nurses, who nodded their assent.

She was only sixteen.


I have been engrossed in some blog posts by PalMD who has been ranting against "conscience clauses" here, herehere, here, and here.

Here's what I think about the role of conscience in the practice of medicine.

I think an individual's highest authority is his or her own conscience - which for some includes some kind of belief in God and for some does not.  I don't believe any person should be forced to act against his or her conscience. 

I also believe respecting a patient's autonomy (and, for that matter, a person's moral sovereignty) is a supreme and unimpeachable ethical obligation.

I agree that where a patient's autonomy is foreseeably threatened by the dictates of a practitioner's conscience, that practitioner should recuse him- or herself, either by avoiding the involved medical specialty or by making provisions for prompt disclosure and speedy referral.

What I DON'T agree with or appreciate is insulting physicians for their personal beliefs, addressing them with extreme condescension, or calling them names such as "idiot" or "bigot" simply because they support conscience clauses.  They are not idiots or bigots or freaks with fringe beliefs just because they are in a minority, and to insult and utter all kinds of calumny against them for the sake of their values is to contradict the very respect for autonomy they are being asked to demonstrate and to violate the principles of freedom of belief on which this country was founded. I think telling doctors they absolutely cannot live according to their deepest convictions, and in fact should not be in medicine at all because of them, is a kind of bigotry in itself and as disrespectful of a person's highest authority as it would be to force a blood transfusion on a Jehovah's Witness.

Now, I abhorred many of the Bush policies as much as anyone who rejoiced on January 20 this year, as I did, when Barack Obama was inaugurated as potentially one of the most brilliant presidents this country will ever see.  I celebrated in the days following Inauguration, too, when Obama took prompt action to do something concretely life-affirming and just: close Guantanamo.   I am truly glad Bush's sorry, damaging administration is at an end.  But I don't believe either Bush or Obama governs the intellectual and spiritual terrain encompassed by my conscience.

I spent my childhood under martial law. Though I was shielded from its most horrifying effects, I remember what it was like to be taught that I had to be careful what I said, where I went, and when.  It felt like a violation of my natural rights as a thinking individual, even at that tender age.  I condemn any regime that attempts to control the lives and attitudes of the people it serves - whether it's a president obliterating due process, a doctor, nurse practitioner, or pharmacist tyrannically imposing a moral code on a patient, or a legislative body thrusting laws upon a particular group - women, married couples, believers, non-believers.  I think there are ways for all physicians, regardless of personal belief, to practice ethically and uphold the standard of care - again, for example, by prompt, respectful disclosure, thorough explanations of treatment possibilities, and speedy, dignified referral.  

As for my young patient who terminated her pregnancy:  I would never have refused to take care of her in the situation she was in when she arrived, no matter what led to it.  I do think of the termination of a pregnancy as the termination of a human life; I did weep inwardly with her, though she couldn't see it; and I wish she hadn't felt she had to take that painful step.  But I also don't believe I'm entitled to take away her right to make decisions about her own life according to her own conscience, any more than I believe it's anyone else's right to prevent me from living according to mine.

*The patient and events described here are a composite of several different clinical cases.


katy (aka funny girl) said...


rlbates said...

I agree that there should be no name calling on either side. I don't think you should be required to give up your conscious any more than anyone else. What I worry about T is pharmacists in small towns who might refuse to fill BCP scripts or who might refuse to care for someone who is homosexual because they don't approve of that person's choice. Those "unforeseen" consequences of the Conscience Rules trouble me more than the obortion choices or refusals to participate in.

And if you/I don't want to participate in medical care due to conscience, should you/I be protected if we don't take make sure the patient is seen by someone who might. How far does the protection go? If I won't take care of said person, does it offend my "conscience" to send them to someone who would.

You write so well and I am truly glad you have the freedom to speak up. Amen to that freedom.

T. said...

Excellent points, Ramona, and I have the same worries. I thing it's completely WRONG to refuse to care for someone who needs medical care. Period.

I think problems arise in people's minds because of different understanding of what the words "medical care" mean. I can't imagine any reason a homosexual could validly be refused treatment. Those who vehemently, categorically oppose abortion, though, are unable to conceive of abortion as "treatment" and therefore cannot wrap their minds around it being included in the category of "medical care."

Pharmacists have no right, as far as I see it, to fail to dispense a medication legally prescribed by a qualified practitioner. That's one profession in which perhaps I would agree it's harder to "recuse yourself" once you're already in practice and perhaps a thorough discernment of the responsibilities beforehand is best. For physicians it's a little easier to avoid specialties in which one might be required to provide services out-of-keeping with one's beliefs - there are so many possible specialties to choose from.

As for your wise warning about the slippery slope / how far the protection goes: it's true, if you wouldn't do something yourself, it might be hard for some to justify sending a patient to someone else who would. But it's also wrong, I think, to take away someone's agency if he or she has made a firm decision and the choice then becomes carrying out that decision safely, competently, and legally versus in an underground clinic with sham practitioners under sketchy conditions (I saw a cop/forensic show on TV in which an example of the latter was sex-change surgery in a basement in which the patient died of hemorrhage.)

None of this is easy. I guess my bottom line is that I don't want someone forcing me to go against my conscience, but I also don't want anyone (including me) to use his or her conscience as an excuse to trample over a patient's rights.

Brian said...

Another great post and thoughtful follow-up, with your customary style and substance. You continue to amaze...

Transor Z said...

T., wonderful post. This has special resonance for me as an attorney. We don't talk about doctors refusing patients or treatment requests -- that are otherwise legal -- nearly as often as we talk about attorneys representing persons or corporations who are "obviously guilty," "despicable," "monstrous," etc.

Whereas the value of compassion is emblematic of doctors, not so much for my much-maligned profession. "Pragmatism" is probably more like it.

You might be interested to know, however, that the Rules of Professional Conduct permit attorneys to express their moral qualms to clients. The client is nearly always the boss, however -- and rightly so -- but professional ethics do allow for the possibility that unresolvable moral conflicts will occasionally develop.

Setting aside doctors and lawyers, how about conscience and CPA firms auditing/advising companies? Someone said a civilized person is one who can look at a column of numbers and weep. How often do we hear about accounting firms refusing clients because they have moral problems with the way they (legally) move money around to the detriment of employees, the environment, the betterment of society? Maybe never?

All too often, our free capitalist society has a term for persons of conscience in the professions -- "not a team player."

This is such an important topic, T., for so many reasons right now, as we watch the terrible chickens come home to roost. As rlbates said above, there are certainly unforeseen consequences to allowing professionals to subordinate client/patient decisions to our consciences.

Kolla said...

Hear hear!
Takes a strong person with integrity and character to be able to honor own views but also respect others.

Props to you and thanks for an insightful, humane and well written blog.

T. said...

Kolla, thank you very much!

Transor Z - what wonderful insights (and challenges) from other fields. I'm so glad you brought them up.

Brian - I know you're biased, but thank you all the same!

Jo said...

Thank you for a well written and thoughtful post.

It is not right for anyone to force their beliefs on others, whether that is a doctor on a patient, a teacher on a pupil, or one country on another.

If you are finding that your line of work or an activity that you are doing clashes with your morals and beliefs, then, by all means move away from that line of work or activity. But please don't tell me what to think or believe, or presume that you know what is best for me and my life.

T said...

I think that also goes for patients on docs, or docs on other docs...

Transor Z said...

Professional: ... (2)"exhibiting a courteous, conscientious, and generally businesslike manner in the workplace." Conforming to a code of ethics in a learned profession is also part of the definition.

The original Hippocratic Oath covenanted with the deity/deities and forbade euthanasia and abortion, yes? Obviously, no such moral consensus exists in our society today.

I think what we're seeing now is the aggregate result of a secular money-worshipping business culture run amok across all professions.

True enough to say it isn't right for doctors to impose morals on patients, but we also have to live with the consequences of telling doctors that their subjective morals are not welcome in the workplace.

That's what hospital chaplains are for, I guess. And besides, religion and sacred oaths are so un-scientific! ;-)

Anonymous said...

I am a pharmacist & the comments by ribates & T. are offensive to me since they have not kept up with conscious rules of ethics. ANY health care person has the ability to exercise their conscious & in my field of pharmacy, this has been clarified & actually enacted into law. If you are remembering issues from the past - those have been resolved!

In my field, a pharmacist may choose to not dispense a drug based on conscious, however, that applies to ALL uses of the drug & is determined by a written & signed conscious statement at the time of employment - not at the time an rx is presented. So, if someone chooses not to dispense misoprostol for cervical ripening, that same pharmacist cannot dispense it for stomach protection along with NSAIDS. It is not a case by case issue, it is a drug issue & applies to ALL cases, labeled & non-labeled in which that drug might be used. Along with that ability to exercise that option, the pharmacist must always know another pharmacy within "reasonable" distance who is willing to dispense the medication. If that is not possible, another pharmacist will come in to dispense. These mechanisms are all in place at each & every pharmacy - BY LAW. Small towns which have fewer pharmacies are protected & have mechanisms in place for referral or transfer of rxs so there is no patient who is left without care.

Now, for the statement that "a pharmacist has no right to fail to dispense a medication legally prescribed by a qualified practitoner" - that is absolutely not correct and against all pharmacy laws. We refuse to dispense all the time. I average 1-2 rxs per day that have something wrong with them - dose, strength, directions. I also refuse to dispense to a non-English speaker who has an rx for a child with difficult directions. They are referred to a pharmacy who has an employee who speaks that language. If I blindly dispensed them, I would be found negligent. Likewise, we are constantly bombarded by drug seekers who will find someone who will write an rx (or steal a blank & write it themselves). I get 1-2 a month when a physician has been suckered into writing for a CII-III only to find out someone else wrote the same thing the previous day. When contacted, that "qualified prescriber" will actually cancel the rx. I also refuse to dispense a controlled drug a prescriberr writes for him/herself - that is against the law.

So, please, while you are giving all your colleagues in medicine the respect they deserve, please give those of us in other areas of healthcare the respect we deserve. Many have heard headlines, but don't follow up on what happened becasue of those headlines. Unless you are a pharmacist, please don't make assumptions about my field of practice!

T. said...

Anonymous pharmacist - I stand corrected. My comment about a pharmacist not having the right to refuse dispensing a drug was hastily written and poorly thought-out. What I was thinking at the time, but failed to articulate explicitly, is that if a medication is prescribed APPROPRIATELY, LEGITIMATELY, and with no foreseeable major dangers and interactions, by a qualified doctor, then there is NO REASON not to dispense it.

But of course we all rely upon competent, attentive pharmacists to catch dosing errors that might be missed, social situations the prescriber might not be aware of, and possible adverse reactions or interactions, and when those occur, OF COURSE the medication should not be dispensed without adjustment or clarification.

I think what I was thinking was more along the lines of refusing to dispense legitimately prescribed drugs, not for SAFETY reasons, but out of personal discomfort - for example hormones for gender reassignment. But if, as you say, pharmacists have similar options for referral to other pharmacists or pharmacies as physicians do to other physicians, then perhaps this is a moot issue. Admittedly I don't know enough about the practicalities to judge.

Dragonfly said...

Thanks for sharing this. There have been recent developments in Australian law in certain states (Victoria, with Queensland expected to follow) decriminalising it and restricting "conscientious objection".
There are few more contentious areas in medicine than this one, and often the patient sadly gets lost in the middle of it. I hope your patient (or series of patients) recovered.

Kirti said...

Very well spoken...very enlightening to hear your point of view...thanks for linking to this--you are such a great writer!