Personal Beliefs and Professional Duties: Maintaining Your Integrity
Reproduced with permission
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
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
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