Friday, May 8, 2009

Doctor Automomy Vs. Patient Autonomy

What should happen when patient autonomy and physician autonomy appear to conflict?

What if my patient requests a procedure which I believe is wrong to perform? Which is against my conscience?

The Obama Administration has recently proposed removing the new Bush-era regulations concerning the "Conscience Clause" protections for health-care personnel and abortion. Many electrons have been rearranged in internet debates in discussions (usually) narrowly focusing on whether doctors may refuse to provide or refer for abortions.

Limiting debate to abortion allows the many venting spleens to miss the critical point: there is no conflict in reality, rather a division of responsibility.

My position is straightforward. The patient has autonomy and the responsibility to decide what legal medical services to seek. The physician has autonomy and the responsibility to practice in the manner s/he chooses. As a physician, I choose whether to provide or refer for any legal procedure or service for my own reasons. If I decline to refer for a procedure, the patient is free to seek care elsewhere in this very commercial society. If it's abortion, must I walk her fingers through the Yellow Pages?

"But doctor, don't you have a duty to provide what the patient wants"?

No. I have a duty to provide medically necessary care to my patients within my scope of practice under the conditions I determine within the law. If a patient, an insurance company or the government requests my services otherwise, I have the right and, at times, the duty to refuse.

My conditions include obvious items such as my training, skills, location, payment and time of day (I have voluntarily limited myself in some contracts and agreements), but also include my belief systems and ethics.

My responsibility is to answer these questions in each individual case:
What can be done?
What needs to be done?
What should be done?

These answers cannot be separated from either my clinical judgement or my ethics. Many similar situations have critical ethical differences we hide in other language. For instance, how many pronouncements against the "octomom" fertility doctor were couched in medical language such as "it was not indicated" when meaning "it was wrong and should not be done"?

Is it wrong to refuse "octomom" multiple embryos on moral grounds?
Is it wrong to refuse clitorectomies?
To assist suicides?
To refer for abortions?

The patient is free to seek these services. I am free to decline.

As I would not be a slave, so I would not be a master. This expresses my idea of democracy.
Abraham Lincoln


  1. Every doctor has the right to autonomy, but also an obligation to provide the standard of care. What that standard is varies from locale to locale, of course.

    If they cannot (due to training) or will not (due to personal ethics) provide the standard, they should refer to someone who can.

    If you cannot or will not even provide this minimum standard of care, you should not be practicing in a scope in which you could be asked.

  2. I agree with you on the training/competence issue. But if I practice in Nazi Germany and the "standard of care" is to kill "mental defectives", must I refer or quit all practice?

    I realize this is hyperbole, but is the doctor a free moral agent, or are my ethics imposed by the majority?