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, here, here, 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.