Doctors saying no on moral grounds

Survey says many withhold information, referrals for abortion, terminal sedation

February 08, 2007|By Chris Emery | Chris Emery,SUN REPORTER

Many doctors feel they have no ethical obligation to inform patients about controversial medical practices or to make referrals to doctors who think differently, according to a survey of physicians by University of Chicago researchers.

The survey found that about 1 in 7 American doctors believe they can withhold information on moral grounds about treatments such as abortion, terminal sedation for the dying and prescribing birth control to adolescents. Nearly a third believe it is ethical to refuse to refer a patient seeking such treatments.

"The conventional wisdom has been that if a doctor is opposed to something, they should tell patients and refer them to another physician," said Dr. Farr A. Curlin, lead author of the study published today in The New England Journal of Medicine. "Yet there is a substantial minority who disagree with that," he said.

Anne DiMotto, a 21-year-old political science major at the University of Maryland, College Park, said she was surprised to learn of her doctor's moral objections when she called to get a prescription for the emergency contraceptive drug Preven. At the time, she was 18 and a senior in high school in Milwaukee.

The nurse she spoke with said the doctor would not write prescriptions for the drug for "moral reasons" or provide a referral.

"It hit me from left field," said DiMotto, who obtained a prescription from her mother's physician. She never went back to the first doctor and now tries to select doctors whose views are closer to hers. "I'm looking for someone who doesn't have an objection like that," she said.

Curlin said the survey results suggest that patients who might want controversial treatments should educate themselves about medical options and choose their doctors accordingly.

Long-running debate

While it is difficult, if not impossible, to determine how often doctors withhold information or refuse to perform treatments, the results show that it might happen more often than previously thought, Curlin said.

He said there is long-running debate among doctors over the extent to which a physician's personal beliefs should play a role in his or her practice. Some doctors, he said, think they should provide any medical procedures that are legal despite their own moral positions. Others take a different view.

Dr. Gary Smith, an obstetrician and gynecologist at the Women's Health Center at Robinwood in Hagerstown, said he is opposed to abortion and emergency contraception.

Smith, who indicated that he is religious, does not perform abortions or refer patients to other doctors who will. Nor does he counsel pregnant women that abortion could be a choice, he said. "They know it's an option," he said. "They don't need me to tell them abortion exists."

Smith also refuses to prescribe emergency contraceptive pills such as Plan B, which he considers tantamount to abortion. "I was always taught I have two patients: the mother and the baby," he said. "Why would I want to send somebody out to hurt their baby?"

`Conscience clause'

Dr. Mark T. Hughes said he has never heard of a doctor refusing to administer terminal sedation, another controversial procedure included on the survey.

Hughes, an assistant professor of medicine at the Johns Hopkins Berman Institute of Bioethics, said the procedure is rare and involves permanent sedation of a patient suffering from intractable pain or a terminal illness.

"Some doctors see it as a comfort to the patient," he said, "but others may see it as taking an active role in ending the patient's life."

The thorniest question, he said, is whether a patient should continue to receive food and water intravenously after sedation. The uproar that ensued in 2005 when doctors removed the feeding tube of Terri Schiavo, a brain-damaged woman from Florida, evidenced the strong feelings surrounding the issue.

Under a Maryland law known as the "conscience clause," doctors, nurses and pharmacists are not required to perform or participate in a medical procedure they find objectionable. Also, they are not obligated to refer a patient to another health care professional.

In addition to legal protections, Hughes said, professional ethical guidelines have always allowed doctors a degree of autonomy. He said the survey indicates "there is still that sentiment among physicians."

The survey was mailed to a random sample of U.S. doctors in various medical specialties in 2003 and drew 1,144 responses. More than half reported objections to performing abortions when the pregnancy resulted from failed contraception. More than 40 percent said they objected to prescribing contraception for adolescents without parental consent.

Male doctors and those who are religious were more likely to withhold information from patients and to refuse to refer them to other physicians. Curlin speculated that men and women differed because several of the most controversial procedures are those that deal with reproductive medicine and thus disproportionately affect women.

Dr. Ellen M. Whitaker, a gynecologist at Washington Hospital Center in Washington, D.C., said she has refused to perform procedures such as unnecessary hysterectomies that she feels were not healthy for patients. But she said she has few moral qualms with other treatments that arise in her practice.

Doctors have an obligation, she said, to provide patients with complete information. "It all comes down to the issue of patient autonomy," she said. "How can they decide what's best for them if they don't know all the options?"

She said this becomes more of an issue in rural areas, where people might have few options if their doctor has a problem with a treatment. "If you're the only doctor in town," she said, "your patients may be up the creek."

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