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

Doctor Autonomy

Just as a patient has autonomy (self-rule) for health decisions, a doctor has autonomy in practice decisions.

A doctor has autonomy to decide the mode and scope of his/her practice of medicine. Mode, in this context, refers to employment, location, associations, etc. Scope of practice is simply what services the doctor provides. Some conditions of practice are prescibed or regulated by national or local law (such as non-discrimination statutes), and some conditions and practices are prohibited, otherwise current U.S. law allows freedom for doctors to decide these things.

Employee or self-employed? If employed, by whom and under what conditions? Where?
Solo or group practice? Locum tenens? Staff model HMO? Government?
Doing which procedures? Under what conditions? For whom?
(Scope of practice enters into the mode of course, as a doctor needs to perform within the requirements of employment). 

When I chose solo, rural, self-employed practice I accepted certain conditions which came with that decision and are different from other modes of practice. For instance, I have more independence and flexibility to follow my own values, but more responsibility for the business side of practice with less security.  

My scope is based on my training, experience, preferences and belief system. It has changed with time, mostly I have reduced the procedures I perform after my skills atrophied since training (e.g. most joint injections). I no longer do obstetrics for financial reasons. I received no training in procedures I intended to not perform for whatever reason.

My next post will address one threat to this liberty. 

Who is responsible for one's health?

A most important question behind too many health initiatives and medicrat blather is a most basic one.

Who is in charge?
Who is in charge of a person's health?

Is it the patient?
Is it the Doctor?
Is it the Medicrat?

Do you remember the old rhetorical question, "Whose body is it, anyway"?

When I was in training, I was subject to a great deal of instruction to not be "paternalistic" toward patients and to respectfully obey their autonomy. I could advise, warn, and teach, I could give them options and try to help, but ultimately the patient made the decision for him/herself.

Today, however, we are seeing the erosion of patient autonomy and a forced resurgence of paternalism as doctors are blamed when someone makes 'bad choices'. Pay-for-performance (P4P) schemes where the Medicrat decrees the Doctor is responsible for the patient's smoking, weight, exercise, etc. What happened to the patient's autonomy?

It is not the Doctor's prerogative to steal the patient's freedom.
It is not the Medicrat's right to overrule the patient's liberty.
It is a person's right and responsibility to exercise autonomy; self-rule. And to live (or not) with the consequences, whether good or bad.


“Liberty means responsibility. That is why most men dread it.”
George Bernard Shaw