Conscience in the Clinic: When Patient Requests and Physician Ethics Conflict

Conscience in the Clinic:When Patient Requests and Physician Ethics Conflict Matthew A. Allison, MD, MPH Assistant Professor Family and Preventive Medicine

Ethical Theories

Normative Ethical Theory • A principle that can be used to decide what morally ought to be done and the rationale supporting it Bayes M and Henley K. Right Conduct: Theories and Applications. 1983. Random House, New York.

Egoism • One always ought to promote one’s own interest, as the only rational basis for deciding what to do. • Without considering the interests and values of other people

Subjectivism • Moral judgements are simply expressions of personal preferences • “matter of opinion”

Skepticism • Moral judgements can never be known to be true • That is, there simply is no such thing as knowing that an action is right or wrong

Relativism • The validity of moral judgements are relative to some authority • For example, society is the absolute moral authority

Utilitarianism • Morality depends solely on the consequences (ends obtained) of the conduct

Natural Law • The rightness of an action is determined by reference to nature rather than to convention, custom or preferences • In this case, nature = human nature guided by rational thought

Ethical Decision Making

Rights vs. Responsibilities

Rights • A valid claim or entitlement that a person can make to restrict the conduct of others in their dealings with him/her • If there are no other conflicting moral obligations, it is obligatory to respect and individual’s rights

Rights • Types • Positive • Directly providing assistance for the holder of the rights • Negative • Not interferring with the rights of the holder

Responsibility • The sense in which one is responsible for achieving (or maintaining) a good result in some matter. • “Obligations”

Case

Case • You are the resident physician in an OB/GYN clinic seeing patients for urgent care services. The current case is a 17 year-old female accompanied by her mother. The patient presents with dysmenorrhea during her last period. Specifically, she had very little menses and associated lower abdominal cramping. This was 2 months ago. You ask additional historical questions and then state that you would like to do a physical examination. She asks that this examination be done without her mother present.

Case (cont) • As you begin the examination, the patient states that she did a pregnancy test two weeks ago, which was positive. She communicates that this is the result of a "one-night stand" and that she does not want to approach the man who fathered the child. She also does not want her parents to know about this and therefore asks for an abortion to be performed. She insists that this procedure be kept strictly confidential (even to the point of not telling your attendingphysician).

Case (cont) • Of note, you have been certified to complete abortion procedures independently. Although you are not an overly religious person, it is your ethical belief that performing some abortions is unacceptable.

Question #1 • Are you ethically or legally obligated to inform the patient's mother of her daughter's pregnancy?

Question #2 • Must you consult with your attending physician (against the patient's wishes)? • What do hospital rules and professional ethics require here? • What do you tell the patient?

Question #3 • If a physician believes abortion in these circumstances would be morally wrong, what are his or her legal and professional obligations? • Are you legally or professionally bound to refer the patient to another physician for abortion services?

Question #4 • How in this situation and others like it can you best reconcile personal ethical principles and the welfare of your patient?

Conscience in the Clinic: When Patient Requests and Physician Ethics Conflict