May 06 2010
Science-based medicine is, among other things, a tool. Science helps us sequester our biases so that we may better understand reality. Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools. Ethics help us think through situations using an explicitly-stated set of values that most of us agree upon (and in order to get wide agreement, these precepts must be pretty general).
Ethical problems are a normal part of medical practice. In medical school I received a bit of formal didactic education on ethics, and on the floors we often have formal ethical discussions to help understand and resolve conflicts. But ethics are not a weapon used to obtain a result we want; they are a tool to give a framework for understanding and resolving dilemmas. Ethical dilemmas can arise out of may types of conflicts, for example when our personal beliefs clash with those of our patients, or when patients’ and families’ desires conflict. They can also arise when we as physicians are constrained in our actions by outside forces.
For example, if an outside agent, say a government, were to ask us to use our professional relationship with a patient to harm them, but the goal was to achieve a greater good (think Guantanamo), we could look at basic medical ethics principles to help clarify the conflict. I would object on the basis of many of these shared ethics: it violates patient autonomy, it causes them harm, and fails to benefit them. My responsibility to avoid harming my patient trumps my government’s desire to obtain information via torture.
Despite our attempts to use ethics as a tool, there are some areas that are so fraught with controversy that we may not always come to a satisfactory resolution. Should doctors participate in executions? (I say “no” but the question is complex.) What about abortion (which is not, by the way, the topic of this post)? My own interpretation of medical ethics requires me to support a right to abortion for my patients. Some physicians find abortion so abhorrent that they cannot support it. For doctors who cannot—for whatever personal reasons—support a right to an abortion, ethics demand that they serve their patients’ needs above their own. There is no set of data that says that “abortion is harmful to women”, so doctors who oppose abortion cannot claim that science supports their bias. But if a doctor legitimately felt that a particular abortion would bring physical harm to a particular woman, then they must give her the advice they feel is necessary. Conversely, if a doctor feels that a particular abortion may help a particular patient, they must tell the patient.
All this is by way of introduction to a big dilemma. Most doctors don’t work in Guantanamo, and most don’t deal with abortion on a daily basis. But many hospitals in the U.S. have some sort of religious affiliation. Approximately 20% of U.S. hospital beds are religiously-affiliated. How does this affect the care given by doctors working with these institutions?
A new study published in the Journal of General Internal Medicine aims to answer that question. Among primary care physicians (PCPs) polled, about 43% had worked in religion-affiliated institutions. Nearly 20% of these doctors had encountered conflicts with the institution’s religious-based policies. Encouragingly, 86% of these doctors indicated they would refer patients to an institution where appropriate treatment was available. Ten percent indicated that they would offer alternatives available at the religious institution, and about 4% said that they would provide the service in violation of hospital policy. (It wasn’t clear to me from my reading of the study whether this also indicated what doctors actually did, or just what they thought they would do.)
In their analysis, the authors found a number of variables that further illuminate these conflicts. Older physicians where less likely to report conflict, but it isn’t clear whether this is because they fail to perceive an ethical conflict or they just don’t run into problems. One of the most interesting findings was that, “[n]either religious affiliation nor physician-institution congruence was significantly associated with having experienced conflict with religiously affiliated institutions.”
From an ethical perspective, these data are mixed. It is comforting that the polled doctors were more often willing to make decisions based on their patients’ needs rather than institutional policies, but it is disturbing that such significant barriers to care arise from these policies. Transparency is an important concept in the ethical delivery of medical care; motivations, limitations, and expectations should be clear. If, for example, a health care system never allows prescription of birth control, this should be made explicit to all providers and patients, and insurance companies who deal with these institutions should make this clear to their customers to allow for informed decision-making.
On a personal and professional level, I find the intrusion of sectarian values into health care disturbing, especially since most of these institutions take money from federally-funded programs such as Medicare and Medicaid. At the same time, many of these institutions provide significant amounts of charitable care. I do not believe, however, that this creates a balance. Charity is good, but treating human beings with dignity and allowing for the science-based delivery of medical care should be a minimum requirement.
Stulberg, D., Lawrence, R., Shattuck, J., & Curlin, F. (2010). Religious Hospitals and Primary Care Physicians: Conflicts over Policies for Patient Care Journal of General Internal Medicine DOI: 10.1007/s11606-010-1329-6
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