Dismembering the ethical physician

Abstract

Physicians may experience ethical distress when they are caught in difficult clinical situations that demand ethical decision making, particularly when their preferred action may contravene the expectations of patients and established authorities. When principled and competent doctors succumb to patient wishes or establishment guidelines and participate in actions they perceive to be ethically inappropriate, or agree to refrain from interventions they believe to be in the best interests of patients, individual professional integrity may be diminished, and ethical reliability is potentially compromised. In a climate of ever-proliferating ethical quandaries, it is essential for the medical community, health institutions, and governing bodies to pursue a judicious tension between the indispensable regulation of physicians necessary to maintain professional standards and preserve public safety, and the support for “freedom of conscience” that principled physicians require to practise medicine in keeping with their personal ethical orientation.

Physicians’ Beliefs About Conscience in Medicine: A National Survey

“…Most physicians in our study agreed with this approach; however, we observed some dissent among those who believed that physicians are never obligated to do what they believe is wrong. One may suppose that many in this latter group believe that, if it is wrong to perform a procedure, it may also be wrong to help a patient obtain it elsewhere 3,30,31…”

“…Perhaps physicians avoid practicing in areas of medicine they find morally problematic 3,24,33. Perhaps physicians attract patients with similar values 30,34,35.…”

“…Such a perspective suggests that doctors should view themselves as independent moral agents 4-8. Yet, independent moral agents often arrive at different conclusions about controversial ethical questions, which makes it difficult for members of the medical profession to offer patients a unified standard of care 3. A recent and visible expression of this difficulty was seen in the public controversy surrounding the position statement issued by the Ethics Committee of the American College of Obstetrics and Gynecology, which said that physicians have a professional, ethical obligation to facilitate patient access to the full range of legal reproductive services, notwithstanding their moral or conscientious objections to those services 9…”

“…All sides recognize the importance of physicians’ maintenance of their personal moral integrity, and all recognize that the profession makes legitimate demands of its members. Yet, in the face of controversial clinical practices, some emphasize the importance of the individual physician’s judgment, holding that physicians are obligated only to provide those medical interventions they believe are ethically appropriate in a given instance 3. Lawmakers have often affirmed this approach by enacting conscience clauses, which protect physicians from penalties they might otherwise incur if they refuse to provide abortions or other controversial treatments 10-12.…”

Freedom of Conscience in Health Care: Distinctions and Limits

“…The Ontario Human Rights Commission warning that it expects health professionals to “‘check their personal views at the door’ in providing medical care” (Ontario Human Rights Commission 2008 , ¶7 under “Moral or Religious Beliefs”) reflects a perspective that seems increasingly popular in ethical and administrative circles. That perspective is shaped by a variety of assertions, including claims about human rights (Ontario Human Rights Commission 2008 ) or medical professionalism (Gordon 2004 ; Charo 2005 ; Cantor 2009 ) that are sharply contested (Genuis 2006 , 2008 ; Murphy 2005 , 2009a ). The personal impact on frontline professionals of unduly restricting or suppressing their freedom of conscience has been insufficiently considered by ethicists and administrators because the complex relationship between this fundamental freedom and the human person has been inadequately assessed.…”