Conscience in the Clinic:Conscience in the Clinic:When Patient Requests and When Patient Requests and

Physician Ethics ConflictPhysician Ethics Conflict

Matthew A. Allison, MD, MPHMatthew A. Allison, MD, MPH

Assistant ProfessorAssistant Professor

Family and Preventive Family and Preventive MedicineMedicine

Ethical TheoriesEthical Theories

Normative Ethical TheoryNormative Ethical Theory

A principle that can be used to A principle that can be used to decide what morally ought to be decide what morally ought to be done and the rationale supporting itdone and the rationale supporting it

Bayes M and Henley K. Right Conduct: Theories and Applications. 1983. Random House, New York.

EgoismEgoism

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

values of other peoplevalues of other people

SubjectivismSubjectivism

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

SkepticismSkepticism

Moral judgements can never be Moral judgements can never be known to be trueknown to be true That is, there simply is no such thing as That is, there simply is no such thing as

knowing that an action is right or wrongknowing that an action is right or wrong

RelativismRelativism

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

moral authoritymoral authority

UtilitarianismUtilitarianism

Morality depends solely on the Morality depends solely on the consequences (ends obtained) of the consequences (ends obtained) of the conductconduct

Natural LawNatural Law

The rightness of an action is The rightness of an action is determined by reference to nature determined by reference to nature rather than to convention, custom or rather than to convention, custom or preferencespreferences In this case, nature = human nature In this case, nature = human nature

guided by rational thoughtguided by rational thought

Ethical Decision MakingEthical Decision Making

Rights vs. ResponsibilitiesRights vs. Responsibilities

RightsRights

A valid claim or entitlement that a A valid claim or entitlement that a person can make to restrict the person can make to restrict the conduct of others in their dealings conduct of others in their dealings with him/herwith him/her If there are no other conflicting moral If there are no other conflicting moral

obligations, it is obligatory to respect obligations, it is obligatory to respect and individual’s rightsand individual’s rights

RightsRights

TypesTypes PositivePositive

Directly providing assistance for the holder Directly providing assistance for the holder of the rightsof the rights

NegativeNegative Not interferring with the rights of the holderNot interferring with the rights of the holder

ResponsibilityResponsibility

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

CaseCase

CaseCase You are the resident physician in an OB/GYN You are the resident physician in an OB/GYN

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

Case (cont)Case (cont)

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

Case (cont)Case (cont)

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

Question #1Question #1

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

Question #2Question #2

Must you consult with your attending Must you consult with your attending physician (against the patient's physician (against the patient's wishes)? wishes)?

What do hospital rules and What do hospital rules and professional ethics require here? professional ethics require here?

What do you tell the patient? What do you tell the patient?

Question #3Question #3

If a physician believes abortion in If a physician believes abortion in these circumstances would be these circumstances would be morally wrong, what are his or her morally wrong, what are his or her legal and professional obligations?legal and professional obligations?

Are you legally or professionally Are you legally or professionally bound to refer the patient to another bound to refer the patient to another physician for abortion services? physician for abortion services?

Question #4Question #4

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