DIFFICULT MORAL QUESTIONS
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Question 68: May a physician remain in a group that provides morally excluded services?
I am a physician in family practice with a small health maintenance group. It includes three primary care physicians (one an internist), a pediatrician, an obstetrician-gynecologist, a general surgeon, and a psychiatrist. All of us are at least nominal Catholics. We use a community hospital (not Catholic) and refer when necessary to specialists in a nearby larger city, where there also is a well-equipped hospital. But we can take care of most of our patients’ needs, and in most respects the arrangement has worked well.
When we set up the group some years ago, we agreed to adhere to the U.S. Bishops’ Ethical and Religious Directives and to tell patients who asked about contraception, sterilization, or abortion: “We do not offer that sort of thing.” In his previous practice, the obstetrician-gynecologist, Dr. Xander, had refused on medical grounds to prescribe oral contraceptives or IUDs. But he insisted upon—and all of us recognized—the need to help our patients with birth regulation. Since the others were not interested, the pediatrician, Dr. White, and I accepted responsibility for teaching natural family planning (NFP).
Soon, though, White and I realized that Xander was fitting diaphragms and recommending nonprescription contraceptives to many women. When confronted, he admitted “cheating a little on our agreement.” But he defended what he was doing as “the least of three evils” for couples who will not practice NFP consistently. If he did not help them limit their families satisfactorily, he argued, many would leave our group and go elsewhere for oral contraception, sterilization, and abortion. Since the group needed an obstetrician-gynecologist and it would have been very difficult to replace Xander, the others did not wish to press the issue, and White and I reluctantly let it drop.
Recently, however, Xander began prescribing oral contraceptives. White and I again confronted him, and he said that, on his reading of the more recent literature, the low-dosage oral contraceptives are medically acceptable. Xander also argued that the group must offer “more satisfactory family planning services” to retain an adequate clientele. White and I objected that all oral contraceptives, and especially the low-dosage ones, sometimes act as abortifacients, but the others sided with Xander and agreed that he not only could prescribe them but do sterilizations and, when he thinks it appropriate, refer patients for abortion to a physician outside the group. They also decided, despite our protests, that from now on no one in the group would say we do not offer that sort of thing; instead, everyone would direct patients “needing” contraception, sterilization, or abortion to Xander. Even White reluctantly agreed to go along. I said I would think about it, and they let it go at that until next month.
I either must go along or leave the group. That would be difficult for me personally, since all of the patients belong to the group as a whole, and I would not be able to take any of them with me. I would have to uproot my wife and children, and begin practice all over again somewhere else. Up to now, I have been trying to work out a modus vivendi. I continue to advocate NFP and, believing that nobody needs contraception, sterilization, or abortion, never bring them up. No patient has brought up abortion with me; not only do most of our patients know where I stand, but those who are pregnant, or think they might be, can go directly to Xander and normally do. A few have asked about contraception, and I say: “I don’t want to have anything to do with that sort of thing, but you can see Dr. Xander about it.”
I think this approach will satisfy the others, but my conscience is bothering me. Also, I really am worried about whether I could say the same thing if someone does bring up sterilization or abortion.
Analysis:
This question concerns material cooperation in wrongdoing. The obstetrician-gynecologist is, or will be, doing sterilizations and formally cooperating in contraception and abortion. Though the questioner’s cooperation need not be formal, the usual norms regarding material cooperation must be applied. Doing so indicates that, even if the cooperation remains as limited as the questioner now proposes, it will be morally unacceptable. He should investigate alternatives to the two he mentions. If he can find no workable and acceptable alternative, in my judgment he must leave.
The reply could be along the following lines:
In prescribing oral contraceptives, which he regards as an appropriate method of birth regulation, Dr. Xander certainly intends that they be used effectively, and he perhaps also intends, but certainly at least wrongly accepts, their sometimes-abortifacient mode of action. Xander is or will be doing sterilizations. And, in referring patients for abortion, which he regards as an element of adequate family planning services, he will intend to make that option available.
In directing patients who ask about contraception, sterilization, and abortion to Dr. Xander, you will be cooperating with him in these matters. Of course, your involvement could remain limited. Holding that these contralife procedures are not appropriate methods of family planning and that nobody needs them, you do not bring them up. Thus far, you have told only those patients who ask about contraception that you do not want to have anything to do with that sort of thing but that they can see Xander about it, and you are considering saying the same thing to those who bring up sterilization or abortion. In saying this, you need not intend that patients see Xander, much less that he or they do anything immoral. Your intention can be, and undoubtedly is and would be, simply to make true statements required of you as a condition for remaining in the group. So, in responding to patients’ inquiries, your cooperation with Xander’s wrongdoing need not involve willing anything he or the patient wrongly wills. Still, even such cooperation is morally unacceptable if it is likely to lead one to cooperate more fully, if it gives scandal or impedes bearing witness as one should, or if it is unfair to anyone.
You might suppose that you may refer patients to Xander, much as a physician who is not in a group but under other pressures may refer patients—at least by suggesting a referral service—to someone who will accommodate them (see q. 66, above). But your situation is different. Since you and the other physicians are a group, your professional work and theirs ordinarily is wholehearted cooperation for common purposes, which include your patients’ well-being and community among yourselves both in your professional activities and in sharing their benefits, not least their financial proceeds. This close association is understood by everyone concerned, and the patients you refer to Xander also will remain yours. When you refer someone to him, you know what he will do, and the patient knows that you know. This state of affairs will profoundly affect the significance of your involvement.
At times you certainly will be tempted to intend the same thing Xander wrongly intends. Caring for the same patients, you cannot help joining him in the intention that they survive and enjoy good health. Knowing that wrong things are being done, you will try to forestall some of their injurious effects. If Xander prescribes a contraceptive, you will be concerned that the patient take it correctly and deal appropriately with side effects; if he is planning to do a sterilization, you will be concerned that the couple understand what sterilization is and that the patient not be coerced; and if Xander refers someone for an abortion, you will be concerned that it not be late in pregnancy, when it would be more dangerous to the mother. Caring for your patients even as they engage in contralife acts, you surely will sometimes be tempted to join them in intending the bad means of attaining their ulterior good ends.
Even if you can avoid intending bad means, your involvement in Xander’s wrongdoing, which inevitably will be extensive, is likely to lead at least some of your patients who otherwise would resist temptation to give in to it. Since you have adhered to Catholic teaching up to now, for you to go along with the group’s change of policy will strongly suggest that contraception, sterilization, and abortion are not so wrong after all, and this suggestion will encourage people to rationalize choosing what they previously regarded as wrong. At the same time, you will be inhibited from bearing credible witness to the truth—that is, saying clearly what you believe about these contralife actions and acting in unambiguous harmony with what you say.
The point is especially clear and serious with respect to abortion. Someone is certain to bring it up sooner or later. If you say, “I don’t want to have anything to do with that sort of thing but you can see Dr. Xander about it,” you will give the impression that you regard abortion, not as wrong in itself, but only as repugnant to you. Yet all of the patients served by the group and, indeed, the wider community need to be reminded constantly that human life is sacred and abortion is its wanton destruction. And even though others continue doing that, the fact that you no longer do will undermine their witness.
Moreover, even your limited involvement in abortion will raise a very serious question of fairness to the unborn child. If you were in his or her place, would you not wish a prolife physician your mother consulted to do everything possible to dissuade her from killing you? Nor is involvement in prescribing oral contraceptives free of the issue of fairness. As you and White argued, they sometimes work as abortifacients. Moreover, they do not always work, and then a child comes to be as unwanted and is in danger of being either aborted or resented and, perhaps, abused (see LCL, 514–16).
Consequently, it seems clear to me that you may not comply with the decision of the others even within the limits you have set. But it is not clear to me that your only alternative is simply to leave and begin a new practice elsewhere. While you might be forced to do that, it should be a last resort. You owe it to your patients, including those not yet born, to help them preserve their lives and promote their health. Before leaving, you should communicate with your partners, one by one, in an effort to persuade at least some of them, and especially Dr. White, to insist on keeping to the terms of the original contract. If you win back at least three of your partners, that majority can save and restore the group’s original purpose of providing good care in accord with sound morality. Your patients, who came to the group on that basis, deserve nothing less.
Even if you do not persuade enough—or any—of your partners, in my judgment you should not go quietly, but should consult a competent lawyer, unless you already have done so, about possible legal steps. Perhaps the agreement you made in setting up the group—to practice in accord with the Church’s teaching—remains legally binding on the others, so that they cannot amend it without your consent. In that case, you can insist that they abide by it. Perhaps the status of the agreement is not so clear, but their position could not be easily defended. In that case, perhaps you can refuse to leave, refuse to cooperate with the new policy, and even openly oppose it. The resulting conflict will be painful for all concerned and may lead the others to offer you some sort of fair settlement. Even if the conflict drags on for a long time, your refusal to refer patients to Xander for immoral procedures and your open opposition would change the significance of your involvement, so that, if you were careful, you could avoid doing anything morally unacceptable.
But perhaps the legal situation is clear, so that you plainly must either cooperate, at least at the level you propose, or leave. In that case, I believe you must leave. Losing your share in this practice certainly will be a great sacrifice. However, you should compare it with the greater sacrifices, including life itself, that many other Christians gladly have made in order to keep the faith.244 You still will have your training and experience in a very remunerative profession. Even if you establish a new practice in some community too poor and/or small to have a physician up to now, you probably will be able to live as well as your neighbors, and Christians dedicated to service should be willing to share, insofar as necessary, the lot of those they serve. Moreover, in due time, you will be compensated very well for your deprivation: “Blessed are those who are persecuted for righteousness’ sake, for theirs is the kingdom of heaven” (Mt 5.10).