The Relationship Between Physicians and Patients
Setting aside the usual hot button issues in bioethics - stem cell research, end-of-life decision making - Edmund Pellegrino, chairman of the President's Council on Bioethics, focused on "the relationship between physicians and patients" in his recent talk, "The Catholic Conscience, Bioethics, and the Public Square," at Santa Clara University.
Pellegrino began this year's Regan lecture for the Markkula Center for Applied Ethics by citing a recent ruling of the American College of Obstetrics and Gynecology. As described by the American Medical Association newspaper, "The ACOG ethics committee opinion said physicians who have religious or moral objections to 'standard practices,' such as abortion, sterilization or the prescribing of contraceptives, are not ethically obligated to provide those services but do owe patients a timely referral to another doctor willing to deliver them."
To Pellegrino, this provision violates the Catholic bioethics doctrine that a physician cannot be complicit in an act that is implicitly wrong. "I cannot send you to someone else" for a procedure that I would refuse to do on moral grounds, he said. He viewed the ACOG ruling as part of a trajectory in modern medicine toward the idea that "one should separate his personal beliefs and submerge them in the role of the physician."
In contrast, Pellegrino argued that conscience is a natural right - that it is fundamental and cannot be overridden by other pressing concerns. In support, he quoted John Paul II's, "The Gospel of Life": "To refuse to take part in committing an injustice is not only a moral duty; it is also a basic human right. Were this not so, the human person would be forced to perform an action intrinsically incompatible with human dignity."
Pellegrino went on to locate one of the main competing principles in modern medicine's concern for autonomy and the evolution in thinking about autonomy from its beginnings as a negative right - to refuse treatment, for example - to its current position as a positive right - to demand particular treatments.
But autonomy, Pellegrino argued, is "a reciprocal arrangement." While patients have autonomy based in their dignity as persons, he said, so do physicians, nurses, and pharmacists. "Can you ask me to do something that violates my deepest professional beliefs?" he asked.
Several recent efforts do just that, Pellegrino maintained. In Oregon, physicians have the right to conscientious objection to the state's assisted suicide law, but pharmacists do not. They must fill prescriptions for lethal drugs.
Pellegrino also described a move in the UNESCO Bioethics Committee - defeated for the present - to mandate that physicians in all signatory nations provide full reproductive services including in vitro fertilization, abortion, and mandatory HPV vaccination.
These efforts to force physicians to do everything that is legal are part of what Pellegrino sees as a paradigm shift in medicine from "covenant to contract." "Over the long history of medical ethics," he said, the relationship between patient and physician "was something more than a civil contract for services." The patient relied on the physician's expertise and personal integrity. "With today's autonomy movement," he said, "you hire the doctor and he's to do what you want him to do."
While Pellegrino welcomed many aspects of autonomy, he argued that "absolutizing" it above every other principle was leading to undesirable consequences. He offered several areas where he thought it must be limited:
"When a grave, probable, definable harm to another person is involved, you don't have autonomy," he said. Citing the case of a commercial pilot he once treated who had an obsession with putting his aircraft into a dive with passengers on board, he argued that as a physician, he had the duty to inform the patient's employer about his psychiatric condition, even though that went against the patient's wishes.
"When you encroach on the autonomy of others," Pellegrino said, your autonomy is also limited. Asking a doctor to perform a treatment he or she considered injurious would be an example.
"There should be a balance," he concluded, "I should not impose on you; you should not impose on me. Moral neutrality is a myth. Everybody has values. Autonomy is itself a value."
Pellegrino offered some practical suggestions for how this balance could be achieved in the real world. One was for physicians to create a brochure laying out their relevant personal principles so that patients could make informed decisions when they selected their health care provider about whether their belief systems would be compatible.
In the final analysis, Pellegrino said, patients are better off with a physician who is a person of principle. "When you have a need - when you're sick, when you're injured, when you're dependent and anxious and in the power of some other human being - what kind of person do you want [to help you]?" he asked. "One who's morally neutral, who will negotiate anything you want, or one who has a set of moral principles and tells you what they are?"
Funding for this lecture is provided by the New York Life Insurance Company in honor of William Regan III and a gift from Ann and William Regan. It was part of Science and Health Horizons, a series of events designed to enrich student, faculty, and community understanding of modern health care topics, supported by the Gerald and Sally DeNardo Lectureship.
Miriam Schulman is the communications director of the Markkula Center for Applied Ethics at Santa Clara University. She wrote this article for "The Valley Catholic" and "The Catholic Herald."