Friday, February 23, 2007

Conscience and modern medicine.

"A doctor's conscience has little place in the delivery of modern medical care." - New England Journal of Medicine[1]

"The doctor ... if not living in a moral situation ... where limits are very clear, ... is very dangerous."
- Auschwitz survivor.[2]

There was a "special article" published in the New England Journal of Medicine last week which a friend brought to my attention. Entitled, "Religion, Conscience, and Controversial Medical Practices"[3], it purports to "determine what practicing physicians think their obligations are when a patient requests a legal medical procedure to which the physician has a religious or other moral objection."[4] The issue, as the introduction states, has been brought to a head by pharmacists and physicians refusing to dispense contraception. Although several states have passed "conscience laws" protecting medical personnel from repercussions when they refuse to participate in immoral activities, the existence of these laws has the medical establishment gnashing its teeth. "In the wake of recent controversies over emergency contraception, editorials in leading clinical journals have criticized these 'conscience clauses' and challenged the idea that physicians may deny legally and medically permitted interventions, particularly if their objections are personal and religious."[5] The authors are quite correct. Two leading medical journals have published the following verbatim assessment of the problem: "... a doctor's conscience has little place in the delivery of modern medical care ... if people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors."[6]

In the NEJM study, the authors polled 1820 physicians, receiving 1144 responses. They asked the physicians whether they believed it ethically permissible to explain their moral objections to patients, whether they thought it necessary to explain all options (including "controversial" ones) to patients, and whether they felt obliged to refer a patient to a physician who would perform the "controversial" procedure. The authors also attempted to assess the degree of "intrinsic religiosity" in the physician respondents, and obtained their answers (object, or don't object) to the following "clinically controversial" situations: "terminal sedation" in a dying patient, providing an abortion in the case of failed contraception, and prescribing birth control to a minor without parental approval. Answering the "intrinsic religiosity" questions, the respondents sorted roughly into thirds (low, 37%; moderate, 27%; high, 36%). On the "terminal sedation question, 83% did not object, and 17% did object.[7] Regarding the questions of abortion and contraception, however, things were more evenly split: 48% for and 52% against on abortion, and 58% for and 42% against on contraception. On the final questions, 63% thought the physician should tell the patient why he objects to the procedure, 86% thought they should tell all options, and 71% thought the physician should refer.

On that last question, "obligation to refer", the authors made an astounding claim. They took the percentage who answered "no" (18%), and added that to the percentage who were undecided (11%). They took the sum, 29%, and multiplied it by the population of the United States and said, "... nearly 100 million Americans may be cared for by physicians who do not feel they have an obligation to refer..." They followed a similar scheme to make this claim, "... more than 40 million Americans may be cared for by physicians who do not believe they are obligated to disclose information about medically available treatments they consider objectionable."[8] As if people don't know about abortion and birth control pills.

The authors then worried that about half the physicians objected to abortion for failed contraception, and that about half didn't want to give birth control to minors without parental consent. Finally, the authors made a point that "male physicians and those who are religious are most likely to express personal objections and least likely to disclose information about the interventions or refer patients to more accommodating providers."[9]

I am no stranger to the fact - for fact it is - that the American medical establishment is a major supporter of moral relativism Yet, when I read this article, I was floored: the overarching arrogance of these people just numbs the brain. Let me be clear. The fundamental issue here isn't whether a majority of physicians are for or against abortion or birth control pills; the fundamental issue here is that the American medical establishment rejects the idea that there exists an objective moral order. This fact is stated explicitly. The "conscience clause" controversy, according to another New England Journal of Medicine paper, "represents the latest struggle with regard to religion in America."[10] Because the medical establishment rejects any moral order, it is simply unable to see the "controversial procedures" for what they are: the very seeds of the culture of death. Contraception, its twisted sister abortion, the bastard stepchildren of euthanasia, embryonic stem cell research, vaccines and medicines manufactured from aborted humans, and all the rest; they are not "controversial procedures", any more than murder is. They are intrinsic evils. And, if one recognizes murder for what it is, and is unwilling to do the deed oneself, one doesn't refer to someone who is. The medical machine simply doesn't get it.

"Conscience has no place in medicine." So say the contemporary medical intelligentsia: the writers and editors of the elite medical journals, who occupy the most prestigious university positions. Well, I say thank God that a "substantial number" of individual, work a day docs do still have a conscience, and the courage to act according to that conscience. For without that conscience we are no more than technological barbarians, and no different from those physicians who stood on the ramps at Aushwitz and Dachau decades ago as the trains pulled in, sorting the prisoners into to lines, one line to live, the other line to die.

[1] Curlin, FA et al. Religion, Conscience, and Controversial Clinical Practices New England Journal of Medicine 356(6):593-600, 8 February 2007.
[2] Lifton, RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide Basic Books Inc., New York, 1986. Pg. 430.
[3] Curlin, ibid.
[4] ibid.
[5] ibid, my emphasis.
[6] Savalescu J. Conscientious objection in medicine. British Medical Journal 2006; 332:294-7. The quote was repeated in the NEJM article under discussion.
[7] I thought this question was ambiguous. The definition of "terminal sedation" given in the paper was, "administering sedation that leads to unconsciousness in dying patients". As written, this description is not necessarily equivalent to "euthanasia", though one suspects that it might be a euphemism.
[8] Curlin, ibid, pg. 597
[9] ibid, pg. 600. My emphasis.
[10] Charo RA. The celestial fire of conscience - refusing to deliver medical care. New England Journal of Medicine 2005; 352:2471-3.

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