DIFFICULT MORAL QUESTIONS
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Question 66: May a physician refer patients who desire morally excluded services?
I am a Catholic obstetrician-gynecologist, committed to carrying on my practice in strict accord with the Church’s teachings. Over the years, that has resulted in an increasingly wide gap between what I am prepared to do and what many other competent physicians regard as good medical practice.
When a woman straightforwardly asks for contraception, sterilization, or abortion, I can refuse to accept her as a patient or tell her I no longer wish to care for her. I have done that many times. Sometimes, however, circumstances make things more difficult. Instead of a straightforward request, I am confronted with a situation in which offering and recommending contraception, sterilization, or abortion would be considered appropriate by most fellow specialists practicing in this region. In not proceeding as colleagues would in such cases, I could be regarded as falling short of the standard of good practice, and that makes me vulnerable to being sued for malpractice. For example, serious health conditions sometimes indicate that a woman should avoid pregnancy, while past experience makes it clear she and her husband will not effectively use NFP. Most of my fellow specialists would recommend tubal ligation if the problem is permanent and contraception by anovulants—unless something precludes prescribing them—if it is temporary. Again, many colleagues routinely check every pregnancy for congenital defects and, finding any, more or less strongly suggest abortion, depending on the defect’s seriousness.
One such problem is dealt with explicitly by the AMA Code of Medical Ethics. In a section on genetic counseling that allows for physicians whose consciences and moral values lead them to limit or avoid “genetic services,” the Council on Ethical and Judicial Affairs adds: “However, the physician who is so disposed is nevertheless obligated to alert prospective parents when a potential genetic problem does exist, so that the patient may decide whether to seek further genetic counseling from another qualified specialist.”239
Can I fulfill that “obligation” and those like it in other sorts of cases, such as those I have mentioned, without violating the Church’s teachings? It seems to me hypocritical to say to a patient: “In a case like this, most of my colleagues would recommend abortion. But I think abortion is wrong, even in a case like yours, so I am not recommending it. At the same time, I don’t want you to go to the neighborhood abortion clinic. Therefore, if you want an abortion, I suggest that you see Dr. . . ..” But, then, what should I say instead?
Analysis:
This question calls for the derivation of a specific moral norm. Physicians usually formally cooperate with the services for which they refer. So, cooperating materially with morally unacceptable services by referring patients to physicians who will provide them would undercut the questioner’s witness and good example, and might cause scandal. If a pregnant patient wants a morally unacceptable option, the questioner should try to save the child. If that effort is rejected or if a nonpregnant patient wants a morally unacceptable option, the questioner should decline to serve any longer as that patient’s physician and should warn her against any foreseeable, dangerous action or omission. If necessary to forestall professional sanctions or civil liability, the questioner may inform the patient about an available referral service.
The reply could be along the following lines:
Whether or not it is hypocritical to give the advice as you formulate it, I think your instincts are entirely correct in rejecting that formulation. If you provide a referral to a particular physician, your advice will be unhelpful, and seem to the patient dishonest, unless that physician will provide the service you regard as morally excluded. But if your advice directs the patient to someone who you expect will provide the morally excluded service, giving the referral will strongly suggest that your own stand is weak and superficial. Since physicians making referrals ordinarily intend that the patient receive the service for which he or she is referred, a patient so referred and others hearing about it would reasonably think: “This physician does not wish to dirty his/her own hands with things like abortion but does not mind having others do them.” In other words, your witness and good example would be undercut and a bad example given in their place.
As to the opinion of the AMA’s Council on Ethical and Judicial Affairs regarding genetic services, I see no special problem. Your principles are entirely compatible with offering appropriate genetic services.240 To do so, however, and also to deal appropriately with analogous problems, I believe you must take care in establishing your relationship with each new patient to tell her at the outset what your principles are and that you intend to practice exclusively in accord with them. Patients unwilling to accept your services on this basis will go elsewhere. But when your services are accepted on this basis, it establishes the common understanding and sharing of purposes essential for the true cooperation that should characterize every authentic physician-patient relationship.241
Even within this framework, though, cases will arise in which most other competent specialists in your field would recommend contraception, sterilization, or abortion. What should you do?
In many cases, patients themselves will think of those options, or other people will call them to their attention. It is appropriate for you to face them frankly and make the case against them. Say: “Here is the problem. Physicians who see nothing wrong with contraception (sterilization, abortion) very likely would recommend that way of solving the problem. But, as you know, I consider contraception (sterilization, abortion) wrong and reject it. Instead I recommend such and such, for such and such reasons.” Having established a clear framework for your relationship with your patients and now recommending an approach within that framework, you may reasonably expect that your advice will be accepted.
If not? Then you should remind the patient of the basis on which your relationship was established, and try to persuade her to continue on the same basis. If that fails and the woman is pregnant, the baby also is your patient, and you should do what you can, consistent with other moral obligations, to try to save him or her (see q. 65, above). But if that effort also is futile or the woman is not pregnant, gently inform her that you no longer will serve as her physician. In saying that, you perhaps will foresee the danger that the patient will fail to obtain necessary care or will act inappropriately and dangerously. You may advise the patient not to neglect her problem and/or warn her against some inappropriate action, for example: “You must not let this go, so you should see someone else as soon as possible” or “Don’t march off to the neighborhood abortion clinic, for they will simply do an abortion, while ignoring other aspects of your problem.”
If nothing more is necessary to save you from serious professional or civil liability, I see no reason why you should offer any further advice. But let us suppose that stopping at this point would open you to disciplinary action or a malpractice suit. Given such pressure, I think you may go one step further. Without recommending any particular physician, you could tell the patient about available medical referral services, for example: “Since you no longer will be seeing me, no doubt you will wish to find another physician. If you do not know whom to see, you can call such and such a referral service for suggestions.”
This formula, unlike the one you articulated and we both rejected, does not suggest that you approve of what is morally excluded and desire only to avoid doing it yourself. So, this advice will not undercut your witness or give bad example, especially if you point out that you are giving it only because of professional and/or legal pressures. Moreover, telling patients about a referral service does not greatly increase the likelihood that they will act on their plan to do what they should not. Then too, in some cases the physician to whom they are referred may at least offer for consideration a morally acceptable approach and perhaps even recommend it. Finally, referring in this indirect way is unlikely to weaken your own commitment and lead you to intend anything you should not. Hence, it seems to me morally acceptable to tell such a patient about available medical referral services when that is necessary to avoid serious problems.