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Protection of Conscience Project

Service, not Servitude

Personal Beliefs and Professional Duties: Maintaining Your Integrity

Reproduced with permission

Dr. Larry Reynolds *

Physicians must be able to maintain their integrity and consciences and to decline to participate in care that they reasonably believe to be harmful to the patient or to others. To do otherwise would herald the twilight of medicine as a noble and compassionate profession.

In modern heath care the role of the physician is at risk of being reduced to becoming a mere tool of the patient's will. The doctor's role will be just to provide services that patients demand. Autonomy of the patient trumps all. This view impoverishes our profession, degrades doctors to mere technicians and will accelerate the moral wasting disease presently plaguing Canadian health care.

Many cultural factors drive this perspective, like our radical individualism and anti-authority stance. We come to view ourselves as infallible authorities in our personal kingdoms...a nation of individual tyrants. "Therefore a Pope, religion or any system that would have us believe in an overarching truth must be discredited." Our dominant post modern view is that of happy nihilism… we are happy as long we don't believe in anything. Anyone who believes in something absolute is a fanatic or terrorist

This makes individual physicians who believe in something or who are "religious "suspect. That is unless their beliefs are just a hobby that does not have any impact on how they live or practice medicine. However believing in something and acting in a different way is a good definition of hypocrisy. Physicians must be able to maintain their integrity while practicing medicine by being true to their deepest values and beliefs. I doubt that most Canadians would wish that physicians of many faiths should either be excluded from the practice of medicine or be required to sacrifice their integrity and become hypocrites in order to practice.

Some have suggested that physicians be mandated to state their beliefs and values up front to patients. Do we assume that this would apply only to religious physicians? What about born again atheists; would they be exempt from such declarations? Patients I suspect are not so much interested in detailed value statements but rather in their experience of the doctor's values of caring, compassion and competence.

So what does this mean about how we navigate value collisions between patients and physicians? Medical indication is one suggested solution but indicated by whom? Unhappiness can be seen as a disease so that if patients do not get their way this creates an automatic indication. On the other hand physicians can misuse the term "not medically indicated" to deny patients therapies because the physician does not share the patient's value of the outcome. This makes medical indication too plastic a term to be of any real use.

Many values collisions occur around the issues of human sexuality and care at the beginning and end of life. Physicians must have the patient's interests as paramount. Physicians acting out of conscience and integrity must do so in order to avoid what they reasonably believe is harmful to the patient or to others. Abortion is often the test case when a physician refuses to do something she believes is harmful to her patient or patients (woman and fetus).

Perhaps a less inflammatory case is the very young woman requesting oral contraceptives. Physicians often fall into one of two camps. The good girl camp… "How wise of you to come in and here is your prescription and a big handful of condoms" or the bad girl camp "you are a very bad girl and I am going to call your mother 'cause you are on the fast track to hell, girl".

Both are in their own way dismissive.

Somewhere between these caricatures lies another way. Caring clinicians know that sex in very young women is almost always exploitive and abuse related. Most also know that contraceptives don't work in very young women because they mostly don't take them. The heart break and broken bodies of your women involved in premature sexual activity is evident to all. Those who care will take the time to find out from these very young women: why now, how old her partner is, what she hopes for from the relationship, whether it is consensual, what the young woman understands about risks and what she will do about the almost inevitable pregnancy or STI. Some then may, with regret, prescribe with the idea that if you are going to drink and drive you might as well wear a seatbelt some of the time. Others will not because they believe that the relationship is harmful contraceptives don't work and they as a physician can not be part of the epidemic of sexual exploitation of women.

These conversations can only occur in climate of respect, care and gentle truth telling. Only in this type of interchange can the truth be discovered and agreements forged. Patients know very quickly if they are cared for, written off (often with a prescription) or condemned. A request for a specific action whether it is a request for an elective Caesarean Section, euthanasia or a disability certificate often have more important secondary questions. These may be: do you care about me, will you listen to my story or do you understand? As doctors (me included) we can get too much of our exercise jumping to conclusions. This is often because of working in a pressurised health system. Maintaining your integrity takes time, experience and moral courage.

It has been rightly pointed out that medicine in the past has suffered from the power abuses of paternalism. This can not be corrected by abdicating our responsibilities and by shifting all the power to patients and promoting" patientism". Physicians must be able to maintain their integrity and consciences and to decline to participate in care that they reasonably believe to be harmful to the patient or to others. To do otherwise would herald the twilight of medicine as a noble and compassionate profession.


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